Form DHCS6239A "Request to Amend 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 DHCS6239A?

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 DHCS6239A 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 DHCS6239A "Request to Amend 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
DEPARTMENT OF HEALTH CARE SERVICES
PRIVACY OFFICE
REQUEST TO AMEND PROTECTED HEALTH INFORMATION
BY PARENT, GUARDIAN OR LEGAL REPRESENTATIVE
File Number: __________________
You have the right to request amendments to protected health information which the
Department of Health Care Services, California Children’s Services (CCS) program creates or
maintains. We will act upon your request to amend within 30 days of our receipt of your request. If
your request is denied, we will let you know the reasons for the denial in writing. You have the right
to disagree with our denial of your request for amendment. You may tell us why in a written
statement of disagreement that will be added to your record. If we continue to disagree with your
requested amendment, we may place a note (rebuttal statement) in your record on why we do not
agree with your statement of disagreement. We will send you a copy of our rebuttal statement. You
also have the right, under the Information Practices Act of 1977, to request a review of the refusal to
amend a record by the head of the agency or a designee. Mail this completed form, with a photocopy
of your identification and documentation of your address, 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 WHOSE INFORMATION YOU ARE AMENDING
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 6239a (11/07)
Page 1 of 4
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
PRIVACY OFFICE
REQUEST TO AMEND PROTECTED HEALTH INFORMATION
BY PARENT, GUARDIAN OR LEGAL REPRESENTATIVE
File Number: __________________
You have the right to request amendments to protected health information which the
Department of Health Care Services, California Children’s Services (CCS) program creates or
maintains. We will act upon your request to amend within 30 days of our receipt of your request. If
your request is denied, we will let you know the reasons for the denial in writing. You have the right
to disagree with our denial of your request for amendment. You may tell us why in a written
statement of disagreement that will be added to your record. If we continue to disagree with your
requested amendment, we may place a note (rebuttal statement) in your record on why we do not
agree with your statement of disagreement. We will send you a copy of our rebuttal statement. You
also have the right, under the Information Practices Act of 1977, to request a review of the refusal to
amend a record by the head of the agency or a designee. Mail this completed form, with a photocopy
of your identification and documentation of your address, 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 WHOSE INFORMATION YOU ARE AMENDING
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 6239a (11/07)
Page 1 of 4
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
PRIVACY OFFICE
DAYTIME
EVENING
EMAIL ADDRESS:
BEST HOURS TO
TELEPHONE
TELEPHONE
REACH YOU:
NUMBER:
NUMBER:
(
)
(
)
WHAT LEGAL AUTHORITY DO YOU HAVE TO AMEND THE HEALTH INFORMATION OF 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.
PROTECTED HEALTH INFORMATION YOU WANT TO AMEND
IDENTIFY THE PROTECTED HEALTH INFORMATION IN THE CLIENT’S CCS RECORD YOU
WANT AMENDED:
WHAT YOU WANT THE RECORD TO STATE NOW: (ATTACH ADDITIONAL PAPER IF
NECESSARY)
DHCS 6239a (11/07)
Page 2 of 4
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
PRIVACY OFFICE
STATE THE REASON YOU BELIEVE THE AMENDMENT NEEDS TO BE MADE:
IDENTIFY THE PERSON(S) TO WHOM YOU WANT THE CCS PROGRAM TO SEND THE PHI
AMENDMENT(S). PROVIDE FULL NAME, ADDRESS, AND ZIP CODE. UPON APPROVAL,
AMENDMENT(S) WILL BE SENT TO PERSON(S) IDENTIFIED, AND TO PROVIDERS, HEALTH
PLANS, AND OTHER BUSINESS ASSOCIATES OF CCS PREVIOUSLY SENT THE CLIENT’S PHI.
IDENTIFYING INFORMATION
COPY OF IDENTIFICATION ATTACHED
TYPE:__________________________ (CA DRIVER’S LICENSE, CA DMV IDENTIFICATION
CARD, STATE OR FEDERAL EMPLOYEE ID CARD)
NUMBER:__________________________
I DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION ON THIS FORM IS
TRUE AND CORRECT.
LEGAL REPRESENTATIVE SIGNATURE:
DATE:
DHCS 6239a (11/07)
Page 3 of 4
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
PRIVACY OFFICE
(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 6239a (11/07)
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