Form DHCS6236A "Request for Access to Protected Health Information (Southern California Regional Office)" - City of Los Angeles, California

Form DHCS6236A Printable Pdf
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What Is Form DHCS6236A?

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 DHCS6236A 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 DHCS6236A "Request for Access to Protected Health Information (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 FOR ACCESS TO PROTECTED HEALTH INFORMATION
File Number: __________________
You have the right to request to inspect your protected health information in records which the
Department of Health Care Services, California Children’s Services (CCS) program, 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 your records mailed, you need to send us a photocopy
of your California driver’s license, Department of Motor Vehicles Identification Card, 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
INDIVIDUAL INFORMATION
LAST NAME
FIRST NAME
MIDDLE
INITIAL
ADDRESS
CITY/STATE
ZIP CODE
CLIENT INDEX NUMBER
DATE OF BIRTH
(CIN)
DAYTIME
EVENING
EMAIL ADDRESS
BEST HOURS TO
TELEPHONE
TELEPHONE
REACH YOU
NUMBER
NUMBER
(
)
(
)
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
DHCS 6236a (11/07)
Page 1 of 3
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
PRIVACY OFFICE
REQUEST FOR ACCESS TO PROTECTED HEALTH INFORMATION
File Number: __________________
You have the right to request to inspect your protected health information in records which the
Department of Health Care Services, California Children’s Services (CCS) program, 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 your records mailed, you need to send us a photocopy
of your California driver’s license, Department of Motor Vehicles Identification Card, 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
INDIVIDUAL INFORMATION
LAST NAME
FIRST NAME
MIDDLE
INITIAL
ADDRESS
CITY/STATE
ZIP CODE
CLIENT INDEX NUMBER
DATE OF BIRTH
(CIN)
DAYTIME
EVENING
EMAIL ADDRESS
BEST HOURS TO
TELEPHONE
TELEPHONE
REACH YOU
NUMBER
NUMBER
(
)
(
)
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
DHCS 6236a (11/07)
Page 1 of 3
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
PRIVACY OFFICE
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 YOUR PROTECTED 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
I REQUEST THAT A PERSON OF MY CHOOSING BE ALLOWED TO INSPECT MY
RECORDS.
NAME
TELEPHONE NUMBER (
)
ADDRESS
RELATIONSHIP TO YOU
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
DHCS 6236a (11/07)
Page 2 of 3
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
PRIVACY OFFICE
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.
CLIENT 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 6236a (11/07)
Page 3 of 3
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