Form CDPH 6235 Request for Confidential Communication of Personal Information by Parent, Guardian or Personal Representative - California

Form CDPH6235 is a California Department of Public Health form also known as the "Request For Confidential Communication Of Personal Information By Parent, Guardian Or Personal Representative". The latest edition of the form was released in March 1, 2018 and is available for digital filing.

Download a PDF version of the Form CDPH6235 down below or find it on California Department of Public Health Forms website.

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STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF PUBLIC HEALTH
PRIVACY OFFICE
CONFIDENTIAL
REQUEST FOR CONFIDENTIAL COMMUNICATION OF
PERSONAL INFORMATION BY PARENT, GUARDIAN OR PERSONAL REPRESENTATIVE
You may request the California Department of Public Health to contact you at another address or telephone number,
other than what is in the individual’s personal records or by a different method (such as only by mail or only by
telephone). To obtain the confidential communication, you need to send us a photocopy of your California Driver’s
license, Department of Motor Vehicles Identification Card, other valid identification, and documentation verifying your
authority to represent the stated individual. You will also need to send documentation verifying your address (see
below). Note: Any attempt to falsely gain access to personal information is subject to legal penalties.
Mail, fax or email this completed form to:
Privacy Officer
California Department of Public Health
1415 L Street, Suite 500
Sacramento, CA 95814
(916) 319-9821 ( fax)
privacy@cdph.ca.gov (email)
INDIVIDUAL FOR WHOM YOU ARE REQUESTING A CONFIDENTIAL COMMUNICATION
LAST NAME:
FIRST NAME:
MIDDLE INITIAL:
ADDRESS:
CITY/STATE:
ZIP CODE:
BENEFICIARY ID NUMBER:
DATE OF BIRTH:
DATE OF DEATH: (If applicable)
Death Certification Must be Attached
PARENT, GUARDIAN, OR PERSONAL REPRESENTATIVE INFORMATION
LAST NAME:
FIRST NAME:
MIDDLE INITIAL:
ADDRESS:
CITY/STATE:
ZIP CODE:
DAYTIME TELEPHONE NUMBER (Required):
EVENING TELEPHONE NUMBER:
EMAIL ADDRESS:
BEST HOURS TO REACH YOU:
WHAT LEGAL AUTHORITY DO YOU HAVE TO REQUEST A CONFIDENTIAL COMMUNICATION
ABOUT THE INDIVIDUAL LISTED ABOVE?
PARENT
CONSERVATOR
GUARDIAN
EXECUTOR OF WILL
MEDICAL POWER OF ATTORNEY
OTHER
NOTE: YOU MUST ATTACH LEGAL DOCUMENTATION TO VERIFY THAT YOU ARE THE PARENT, CONSERVATOR, GUARDIAN, EXECUTOR OF A DECEDENT’S WILL, OR
HAVE MEDICAL DECISION-MAKING AUTHORITY FOR THE INDIVIDUAL.
COPY OF LEGAL DOCUMENTATION ATTACHED
TYPE (COURT ORDER/APPOINTMENT OF CONSERVATOR, GUARDIAN, ETC., MEDICAL POWER OF ATTORNEY, ATTORNEY LETTER OF REPRESENTATION,
APPOINTMENT OF GUARDIAN AND LITEM, ETC.):
DIRECTIONS
WHICH CDPH PROGRAM(S) ARE YOU REQUESTING A CONFIDENTIAL COMMUNICATION?
AIDS Drug Assistance Program (ADAP)
OTHER (Please list CDPH program(s) which may have the personal
information)
AIDS Medi-Cal Waiver Program (MCWP)
UNKNOWN (If this box is checked, we will call you to assist in determining
Newborn Screening Program
which CDPH program(s) may have the personal information you are requesting a
confidential communication.)
Prenatal Screening Program
CDPH 6235 (03/18)
Page 1 of 2
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF PUBLIC HEALTH
PRIVACY OFFICE
CONFIDENTIAL
REQUEST FOR CONFIDENTIAL COMMUNICATION OF
PERSONAL INFORMATION BY PARENT, GUARDIAN OR PERSONAL REPRESENTATIVE
You may request the California Department of Public Health to contact you at another address or telephone number,
other than what is in the individual’s personal records or by a different method (such as only by mail or only by
telephone). To obtain the confidential communication, you need to send us a photocopy of your California Driver’s
license, Department of Motor Vehicles Identification Card, other valid identification, and documentation verifying your
authority to represent the stated individual. You will also need to send documentation verifying your address (see
below). Note: Any attempt to falsely gain access to personal information is subject to legal penalties.
Mail, fax or email this completed form to:
Privacy Officer
California Department of Public Health
1415 L Street, Suite 500
Sacramento, CA 95814
(916) 319-9821 ( fax)
privacy@cdph.ca.gov (email)
INDIVIDUAL FOR WHOM YOU ARE REQUESTING A CONFIDENTIAL COMMUNICATION
LAST NAME:
FIRST NAME:
MIDDLE INITIAL:
ADDRESS:
CITY/STATE:
ZIP CODE:
BENEFICIARY ID NUMBER:
DATE OF BIRTH:
DATE OF DEATH: (If applicable)
Death Certification Must be Attached
PARENT, GUARDIAN, OR PERSONAL REPRESENTATIVE INFORMATION
LAST NAME:
FIRST NAME:
MIDDLE INITIAL:
ADDRESS:
CITY/STATE:
ZIP CODE:
DAYTIME TELEPHONE NUMBER (Required):
EVENING TELEPHONE NUMBER:
EMAIL ADDRESS:
BEST HOURS TO REACH YOU:
WHAT LEGAL AUTHORITY DO YOU HAVE TO REQUEST A CONFIDENTIAL COMMUNICATION
ABOUT THE INDIVIDUAL LISTED ABOVE?
PARENT
CONSERVATOR
GUARDIAN
EXECUTOR OF WILL
MEDICAL POWER OF ATTORNEY
OTHER
NOTE: YOU MUST ATTACH LEGAL DOCUMENTATION TO VERIFY THAT YOU ARE THE PARENT, CONSERVATOR, GUARDIAN, EXECUTOR OF A DECEDENT’S WILL, OR
HAVE MEDICAL DECISION-MAKING AUTHORITY FOR THE INDIVIDUAL.
COPY OF LEGAL DOCUMENTATION ATTACHED
TYPE (COURT ORDER/APPOINTMENT OF CONSERVATOR, GUARDIAN, ETC., MEDICAL POWER OF ATTORNEY, ATTORNEY LETTER OF REPRESENTATION,
APPOINTMENT OF GUARDIAN AND LITEM, ETC.):
DIRECTIONS
WHICH CDPH PROGRAM(S) ARE YOU REQUESTING A CONFIDENTIAL COMMUNICATION?
AIDS Drug Assistance Program (ADAP)
OTHER (Please list CDPH program(s) which may have the personal
information)
AIDS Medi-Cal Waiver Program (MCWP)
UNKNOWN (If this box is checked, we will call you to assist in determining
Newborn Screening Program
which CDPH program(s) may have the personal information you are requesting a
confidential communication.)
Prenatal Screening Program
CDPH 6235 (03/18)
Page 1 of 2
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF PUBLIC HEALTH
PRIVACY OFFICE
REQUIRED IDENTIFYING INFORMATION
To process your request, you must provide verification of address and identification.
ADDRESS VERIFICATION ATTACHED
TYPE (UTILITY BILL, PHONE BILL, DRIVER’S LICENSE, ETC.)
COPY OF IDENTIFICATION ATTACHED
TYPE (DRIVER’S LICENSE, DMV IDENTIFICATION CARD, BIRTH CERTIFICATE, BENEFITS IDENTIFICATION CARD, MANAGED CARE CARD, STATE OR FEDERAL
EMPLOYEE ID CARD)
NUMBER:
(IF NO IDENTIFICATION IS ATTACHED, YOUR SIGNATURE MUST BE NOTARIZED.)
NOTARIZED BY
ON
(DATE)
NOTARY PUBLIC NUMBER
UNOFFICIAL UNLESS STAMPED BY NOTARY PUBLIC
I DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION ON THIS FORM IS TRUE AND CORRECT.
REQUESTING REPRESENTATIVE SIGNATURE:
DATE:
DEPARTMENT EMPLOYEE PROCESSING/MAINTAINING THIS REQUEST FOR CONFIDENTIAL COMMUNICATION
THIS SECTION TO BE COMPLETED BY DEPARTMENT STAFF
(Name and Title)
(Organization within Department)
(Telephone Number)
(Mail Stop Number)
PRIVACY STATEMENT (CA CIVIL CODE SECTION 1798.17)
THE INFORMATION COLLECTED ON THIS FORM IS USED TO PROCESS YOUR REQUEST FOR CONFIDENTIAL COMMUNICATION OF PERSONAL
INFORMATION ABOUT AN INDIVIDUAL YOU LEGALLY REPRESENT THAT IS MAINTAINED BY THE CALIFORNIA DEPARTMENT OF PUBLIC HEALTH
(DEPARTMENT). THE INFORMATION WE COLLECT FROM YOU ON THIS FORM WILL BE KEPT CONFIDENTIAL AND ON FILE AT THE DEPARTMENT, AS
REQUIRED BY LAW. ALL INFORMATION REQUESTED ON THE FORM IS MANDATORY PURSUANT TO 45 CODE OF FEDERAL REGULATIONS, SECTION
164.522(b). NOT SUPPLYING THE INFORMATION REQUESTED WILL RESULT IN THE DENIAL OF YOUR REQUEST. ANY INFORMATION PROVIDED
MAY BE DISCLOSED TO THE CALIFORNIA STATE AUDITOR, THE CALIFORNIA OFFICE OF HEALTH INFORMATION INTEGRITY, THE CALIFORNIA
OFFICE OF INFORMATION SECURITY AND PRIVACY PROTECTION, THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES OR TO OTHER STATE
AND FEDERAL AGENCIES AS REQUIRED BY LAW.
YOU HAVE THE RIGHT TO REVIEW THE RECORDS WE KEEP ABOUT YOU DURING NORMAL BUSINESS HOURS. THE CALIFORNIA DEPARTMENT OF
PUBLIC HEALTH PRIVACY OFFICER WILL, UPON REQUEST, INFORM YOU REGARDING THE LOCATION OF YOUR RECORDS AND THE CATEGORIES
OF ANY PERSONS WHO USE THE INFORMATION IN THOSE RECORDS. FOR MORE INFORMATION, CONTACT THE CALIFORNIA DEPARTMENT OF
PUBLIC HEALTH, PRIVACY OFFICE, USING THE FOLLOWING CONTACT INFORMATION: CALIFORNIA DEPARTMENT OF PUBLIC HEALTH, OFFICE OF
LEGAL SERVICES, PRIVACY OFFICE, 1415 L STREET, SUITE 500, SACRAMENTO, CALIFORNIA 95814 OR BY PHONE 1-877-421-9634.
CDPH 6235 (03/18)
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Download Form CDPH 6235 Request for Confidential Communication of Personal Information by Parent, Guardian or Personal Representative - California

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