Form DHCS6235A "Confidential Communication Request (Northern California Regional Office)" - City and County of San Francisco, California

What Is Form DHCS6235A?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. The form may be used strictly within City and County of San Francisco. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2007;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DHCS6235A by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

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Download Form DHCS6235A "Confidential Communication Request (Northern California Regional Office)" - City and County of San Francisco, California

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STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
P
O
RIVACY
FFICE
CONFIDENTIAL COMMUNICATION REQUEST
File Number: __________________
You or your legal representative may request the Department of Health Care Services to contact you
at another address or telephone number, other than what is currently in your California Children’s
Services (CCS) records, or by a different method (such as only by mail or only by telephone). To
request this, mail this completed form to:
Attention: HIPAA Representative
Department of Health Care Services
Children’s Medical Services Branch
California Children’s Services
Northern California Regional Office
575 Market Street, Suite 300
San Francisco, CA 94105
(415) 904-9699
INDIVIDUAL INFORMATION
LAST NAME:
FIRST NAME:
MIDDLE
INITIAL:
CURRENT ADDRESS:
CITY/STATE:
ZIP CODE:
CLIENT INDEX NUMBER
DATE OF BIRTH:
(CIN)
DAYTIME
EVENING
EMAIL ADDRESS:
BEST HOURS TO REACH
TELEPHONE
TELEPHONE
YOU:
NUMBER:
NUMBER:
(
)
(
)
I REQUEST THAT THE DEPARTMENT OF HEALTH CARE SERVICES CONTACT ME AT A
DIFFERENT ADDRESS AND/OR A DIFFERENT TELEPHONE NUMBER THAN WHAT IS LISTED
IN MY CCS RECORDS BECAUSE CONTACTING ME AT MY CURRENT ADDRESS AND/OR
TELEPHONE NUMBER IS A SAFETY ISSUE FOR ME.
ALTERNATE STREET ADDRESS OR POST OFFICE BOX TO CONTACT ME
CITY, STATE
ZIP CODE
ALTERNATE TELEPHONE NUMBER TO CONTACT ME
(
)
I MAY ALSO REQUEST THE DEPARTMENT OF HEALTH CARE SERVICES TO LIMIT THE WAY
IT CONTACTS ME.
DHCS 6235a (11/07)
Page 1 of 2
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
P
O
RIVACY
FFICE
CONFIDENTIAL COMMUNICATION REQUEST
File Number: __________________
You or your legal representative may request the Department of Health Care Services to contact you
at another address or telephone number, other than what is currently in your California Children’s
Services (CCS) records, or by a different method (such as only by mail or only by telephone). To
request this, mail this completed form to:
Attention: HIPAA Representative
Department of Health Care Services
Children’s Medical Services Branch
California Children’s Services
Northern California Regional Office
575 Market Street, Suite 300
San Francisco, CA 94105
(415) 904-9699
INDIVIDUAL INFORMATION
LAST NAME:
FIRST NAME:
MIDDLE
INITIAL:
CURRENT ADDRESS:
CITY/STATE:
ZIP CODE:
CLIENT INDEX NUMBER
DATE OF BIRTH:
(CIN)
DAYTIME
EVENING
EMAIL ADDRESS:
BEST HOURS TO REACH
TELEPHONE
TELEPHONE
YOU:
NUMBER:
NUMBER:
(
)
(
)
I REQUEST THAT THE DEPARTMENT OF HEALTH CARE SERVICES CONTACT ME AT A
DIFFERENT ADDRESS AND/OR A DIFFERENT TELEPHONE NUMBER THAN WHAT IS LISTED
IN MY CCS RECORDS BECAUSE CONTACTING ME AT MY CURRENT ADDRESS AND/OR
TELEPHONE NUMBER IS A SAFETY ISSUE FOR ME.
ALTERNATE STREET ADDRESS OR POST OFFICE BOX TO CONTACT ME
CITY, STATE
ZIP CODE
ALTERNATE TELEPHONE NUMBER TO CONTACT ME
(
)
I MAY ALSO REQUEST THE DEPARTMENT OF HEALTH CARE SERVICES TO LIMIT THE WAY
IT CONTACTS ME.
DHCS 6235a (11/07)
Page 1 of 2
I REQUEST THAT THE DEPARTMENT OF HEALTH CARE SERVICES CONTACT ME
ONLY BY TELEPHONE
ONLY BY MAIL
(PLEASE CHECK ONE)
IDENTIFYING INFORMATION
COPY OF IDENTIFICATION ATTACHED
TYPE__________________________ (CA DRIVER’S LICENSE, CA DMV IDENTIFICATION CARD,
BIRTH CERTIFICATE, BENEFICIARY IDENTIFICATION CARD, MANAGED CARE CARD, STATE
OR FEDERAL EMPLOYEE ID CARD)
NUMBER__________________________
I DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION ON THIS FORM IS
TRUE AND CORRECT.
BENEFICIARY SIGNATURE____________________________DATE_______________
(IF NO IDENTIFICATION IS ATTACHED, YOUR SIGNATURE MUST BE NOTARIZED.)
NOTARIZED BY ________________________________________ ON ___________________
(DATE)
NOTARY PUBLIC NUMBER ________________________________
UNOFFICIAL UNLESS STAMPED BY NOTARY PUBLIC
ADDRESS VERIFICATION ATTACHED
FORM OF ADDRESS VERIFICATION _____________________________ (UTILITY BILL, PHONE
BILL, DRIVER’S LICENSE, ETC.)
NOTE: ANY ATTEMPT TO FALSELY GAIN ACCESS TO PROTECTED HEALTH INFORMATION
IS SUBJECT TO LEGAL PENALTIES.
DHCS 6235a (11/07)
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