Form DHCS6237A "Request to Access Protected Health Information by Parent, Guardian or Legal Representative (Southern California Regional Office)" - City of Los Angeles, California

What Is Form DHCS6237A?

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 of Los Angeles. 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 DHCS6237A 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 DHCS6237A "Request to Access Protected Health Information by Parent, Guardian or Legal Representative (Southern California Regional Office)" - City of Los Angeles, California

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STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
PRIVACY OFFICE
REQUEST TO ACCESS PROTECTED HEALTH INFORMATION
BY PARENT, GUARDIAN OR LEGAL REPRESENTATIVE
File Number: __________________
You have the right to request to inspect protected health information in records which the
Department of Health Care Services, California Children’s Services (CCS) creates or maintains.
You also have the right to request copies of those records. You will be charged for the cost of
copying and postage. You will receive a response to your request within 30 days after we receive
your request. If you want copies of records mailed, you need to send us a photocopy of your
California driver’s license, an identification card issued by the Department of Motor Vehicles or other
valid identification. You will also need to send documentation verifying your address. Mail this
completed form to:
Attention: HIPAA Representative
Department of Health Care Services
Children’s Medical Services Branch
California Children’s Services
Southern California Regional Office
311 South Spring Street, Suite 01-11
Los Angeles, CA 90013
(213) 897-3574
CLIENT WHOSE INFORMATION YOU ARE REQUESTING
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:
DAYTIME
EVENING
EMAIL ADDRESS:
BEST HOURS TO
TELEPHONE
TELEPHONE
REACH YOU:
NUMBER:
NUMBER:
(
)
(
)
DHCS 6237a (11/07)
Page 1 of 4
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
PRIVACY OFFICE
REQUEST TO ACCESS PROTECTED HEALTH INFORMATION
BY PARENT, GUARDIAN OR LEGAL REPRESENTATIVE
File Number: __________________
You have the right to request to inspect protected health information in records which the
Department of Health Care Services, California Children’s Services (CCS) creates or maintains.
You also have the right to request copies of those records. You will be charged for the cost of
copying and postage. You will receive a response to your request within 30 days after we receive
your request. If you want copies of records mailed, you need to send us a photocopy of your
California driver’s license, an identification card issued by the Department of Motor Vehicles or other
valid identification. You will also need to send documentation verifying your address. Mail this
completed form to:
Attention: HIPAA Representative
Department of Health Care Services
Children’s Medical Services Branch
California Children’s Services
Southern California Regional Office
311 South Spring Street, Suite 01-11
Los Angeles, CA 90013
(213) 897-3574
CLIENT WHOSE INFORMATION YOU ARE REQUESTING
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:
DAYTIME
EVENING
EMAIL ADDRESS:
BEST HOURS TO
TELEPHONE
TELEPHONE
REACH YOU:
NUMBER:
NUMBER:
(
)
(
)
DHCS 6237a (11/07)
Page 1 of 4
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
PRIVACY OFFICE
WHAT LEGAL AUTHORITY DO YOU HAVE TO REQUEST 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 ACCESS
WHAT TYPE OF PROTECTED HEALTH INFORMATION DO YOU WANT TO ACCESS?
PROGRAM APPLICATION
FINANCIAL ELIGIBILITY
PROGRAM SERVICE AGREEMENT
RESIDENTIAL ELIGIBILITY
SERVICE AUTHORIZATION REQUEST
NARRATIVES
SERVICE AUTHORIZATIONS
OTHER, SPECIFY __________________
DENIALS
__________________________________
NOTICE OF ACTION
PLEASE BE SPECIFIC AS YOU WILL BE CHARGED FOR EACH PAGE COPIED.
FOR WHAT TIME PERIOD DO YOU WANT INFORMATION?
FROM DATE:
TO DATE:
METHOD TO ACCESS REQUESTED HEALTH INFORMATION
PLEASE MAIL ME A COPY OF THE REQUESTED INFORMATION TO THE ADDRESS
INDICATED ON PAGE ONE OF THIS FORM.
I WISH TO REVIEW THE REQUESTED INFORMATION IN PERSON.
I REQUEST INTERPRETATION SERVICES.
DHCS 6237a (11/07)
Page 2 of 4
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
PRIVACY OFFICE
IF YOU REQUEST TO REVIEW RECORDS IN PERSON, YOU WILL BE CONTACTED TO
SCHEDULE AN APPOINTMENT.
LOCATION OPTION
Attention: HIPAA Representative
Department of Health Care Services
Children’s Medical Services Branch
California Children’s Services
Southern California Regional Office
311 South Spring Street, Suite 01-11
Los Angeles, CA 90013
(213) 897-3574
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:
(IF NO IDENTIFICATION IS ATTACHED, YOUR SIGNATURE MUST BE NOTARIZED.)
NOTARIZED BY: __________________________________ ON ___________________ (DATE)
NOTARY PUBLIC NUMBER: ________________________________
UNOFFICIAL UNLESS STAMPED BY NOTARY PUBLIC:
DHCS 6237a (11/07)
Page 3 of 4
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
PRIVACY OFFICE
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 6237a (11/07)
Page 4 of 4
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