Form DHCS6245A "Request for an Accounting of Disclosures of Protected Health Information by Parent, Guardian or Legal Representative (Northern California Regional Office/San Francisco)" - City and County of San Francisco, California

What Is Form DHCS6245A?

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 DHCS6245A 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 DHCS6245A "Request for an Accounting of Disclosures of Protected Health Information by Parent, Guardian or Legal Representative (Northern California Regional Office/San Francisco)" - City and County of San Francisco, California

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STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
DE
PARTMENT OF HEALTH CARE SERVICES
PRIVACY OFFICE
REQUEST FOR AN ACCOUNTING OF DISCLOSURES OF
PROTECTED HEALTH INFORMATION BY PARENT, GUARDIAN OR
LEGAL REPRESENTATIVE
File Number: __________________
You have the right to request the Department of Health Care Services to account for the
disclosures of personal California Children’s Services (CCS) protected health information. You
are not entitled to an accounting of disclosures to carry out treatment, payment, or health care
operations; when you have authorized the disclosure; or when the disclosure is to the CCS client’s
family, relatives, or others involved in the individuals care. You are also not entitled to an
accounting of disclosures for National Security or intelligence purposes and to law enforcement
officials. A photocopy of your identification and documentation of your address must accompany
this form. 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/ San Francisco
575 Market Street, Suite 300
San Francisco, CA 94105
(415) 904-9699
CLIENT FOR WHOM YOU ARE REQUESTING AN ACCOUNTING OF DISCLOSURES
LAST NAME:
FIRST NAME:
MIDDLE
INITIAL:
ADDRESS:
CITY/STATE:
ZIP CODE:
CLIENT INDEX NUMBER
DATE OF BIRTH:
DATE OF DEATH:
(IF APPLICABLE)
(CIN):
DEATH CERTIFICATE MUST BE ATTACHED
PARENT, GUARDIAN, OR LEGAL REPRESENTATIVE INFORMATION
LAST NAME:
FIRST NAME:
MIDDLE
INITIAL:
ADDRESS:
CITY/STATE:
ZIP CODE:
DHCS 6245a (11/07)
Page 1 of 3
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
DE
PARTMENT OF HEALTH CARE SERVICES
PRIVACY OFFICE
REQUEST FOR AN ACCOUNTING OF DISCLOSURES OF
PROTECTED HEALTH INFORMATION BY PARENT, GUARDIAN OR
LEGAL REPRESENTATIVE
File Number: __________________
You have the right to request the Department of Health Care Services to account for the
disclosures of personal California Children’s Services (CCS) protected health information. You
are not entitled to an accounting of disclosures to carry out treatment, payment, or health care
operations; when you have authorized the disclosure; or when the disclosure is to the CCS client’s
family, relatives, or others involved in the individuals care. You are also not entitled to an
accounting of disclosures for National Security or intelligence purposes and to law enforcement
officials. A photocopy of your identification and documentation of your address must accompany
this form. 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/ San Francisco
575 Market Street, Suite 300
San Francisco, CA 94105
(415) 904-9699
CLIENT FOR WHOM YOU ARE REQUESTING AN ACCOUNTING OF DISCLOSURES
LAST NAME:
FIRST NAME:
MIDDLE
INITIAL:
ADDRESS:
CITY/STATE:
ZIP CODE:
CLIENT INDEX NUMBER
DATE OF BIRTH:
DATE OF DEATH:
(IF APPLICABLE)
(CIN):
DEATH CERTIFICATE MUST BE ATTACHED
PARENT, GUARDIAN, OR LEGAL REPRESENTATIVE INFORMATION
LAST NAME:
FIRST NAME:
MIDDLE
INITIAL:
ADDRESS:
CITY/STATE:
ZIP CODE:
DHCS 6245a (11/07)
Page 1 of 3
DAYTIME
EVENING
EMAIL ADDRESS:
BEST HOURS TO
TELEPHONE
TELEPHONE
REACH YOU:
NUMBER:
NUMBER:
(
)
(
)
WHAT LEGAL AUTHORITY DO YOU HAVE TO REQUEST AN ACCOUNTING OF DISCLOSURES
FOR THE CLIENT ABOVE?
PARENT
CONSERVATOR
GUARDIAN
EXECUTOR OF WILL
MEDICAL POWER OF ATTORNEY
OTHER
PLEASE ATTACH LEGAL DOCUMENTATION VERIFYING THAT YOU ARE THE PARENT,
CONSERVATOR, GUARDIAN, EXECUTOR OF A DECEDENT’S WILL, OR HAVE MEDICAL
DECISION-MAKING AUTHORITY FOR THE CLIENT.
IDENTIFYING INFORMATION
COPY OF IDENTIFICATION ATTACHED
TYPE:__________________________ (CA DRIVER’S LICENSE, CA DMV IDENTIFICATION
CARD, STATE OR FEDERAL EMPLOYEE ID CARD)
NUMBER:__________________________
I REQUEST THAT THE DEPARTMENT OF HEALTH CARE SERVICES ACCOUNT FOR THE
DISCLOSURE OF PROTECTED HEALTH INFORMATION.
FROM: ________________(MONTH/YEAR)
TO: ___________________(MONTH/YEAR)
I DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION ON THIS FORM IS
TRUE AND CORRECT.
LEGAL REPRESENTATIVE
SIGNATURE:_____________________________DATE:_________________
DHCS 6245a (11/07)
Page 2 of 3
(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 6245a (11/07)
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