Form DHCS6241A "Request to Restrict Use and Disclosure of Protected Health Information by Parent, Guardian or Legal Representative (Sacramento Regional Office)" - City of Sacramento, California

What Is Form DHCS6241A?

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 Sacramento. 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 DHCS6241A 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 DHCS6241A "Request to Restrict Use and Disclosure of Protected Health Information by Parent, Guardian or Legal Representative (Sacramento Regional Office)" - City of Sacramento, California

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STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
PRIVACY OFFICE
REQUEST TO RESTRICT USE AND DISCLOSURE OF
PROTECTED HEALTH INFORMATION BY PARENT, GUARDIAN
OR LEGAL REPRESENTATIVE
File Number: __________________
You have the right to request the Department of Health Care Services (DHCS) to restrict the use and
disclosure of the California Children’s Services (CCS) protected health information to carry out
treatment, payment or operations. You also have the right to request DHCS not to disclose CCS
protected health information to a family member, relative, or friend involved with the care or payment
of the individual’s health care. DHCS may not be able to agree with your request. This form must be
accompanied by a photocopy of a form of identification and documentation of your address. Mail this
completed form to:
Attention: HIPAA Representative
Department of Health Care Services
Children’s Medical Services Branch
California Children’s Services
Sacramento Regional Office
1515 K Street, Room 400
P.O. Box 997413, MS 8105
Sacramento, CA 95899-7413
(916) 327-3100
CLIENT FOR WHOM YOU ARE REQUESTING TO RESTRICT THE USE AND DISCLOSURE OF
PROTECTED HEALTH INFORMATION
LAST NAME:
FIRST NAME:
MIDDLE
INITIAL:
ADDRESS:
CITY/STATE:
ZIP CODE:
CLIENT INDEX NUMBER (CIN):
DATE OF BIRTH:
DATE OF DEATH:
(If Applicable)
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 6241a (11/07)
Page 1 of 3
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
PRIVACY OFFICE
REQUEST TO RESTRICT USE AND DISCLOSURE OF
PROTECTED HEALTH INFORMATION BY PARENT, GUARDIAN
OR LEGAL REPRESENTATIVE
File Number: __________________
You have the right to request the Department of Health Care Services (DHCS) to restrict the use and
disclosure of the California Children’s Services (CCS) protected health information to carry out
treatment, payment or operations. You also have the right to request DHCS not to disclose CCS
protected health information to a family member, relative, or friend involved with the care or payment
of the individual’s health care. DHCS may not be able to agree with your request. This form must be
accompanied by a photocopy of a form of identification and documentation of your address. Mail this
completed form to:
Attention: HIPAA Representative
Department of Health Care Services
Children’s Medical Services Branch
California Children’s Services
Sacramento Regional Office
1515 K Street, Room 400
P.O. Box 997413, MS 8105
Sacramento, CA 95899-7413
(916) 327-3100
CLIENT FOR WHOM YOU ARE REQUESTING TO RESTRICT THE USE AND DISCLOSURE OF
PROTECTED HEALTH INFORMATION
LAST NAME:
FIRST NAME:
MIDDLE
INITIAL:
ADDRESS:
CITY/STATE:
ZIP CODE:
CLIENT INDEX NUMBER (CIN):
DATE OF BIRTH:
DATE OF DEATH:
(If Applicable)
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 6241a (11/07)
Page 1 of 3
WHAT LEGAL AUTHORITY DO YOU HAVE TO RESTRICT 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.
CHECK ALL THAT APPLY
I REQUEST THAT THE DEPARTMENT OF HEALTH CARE SERVICES RESTRICT THE
USE AND DISCLOSURE OF THE CLIENT’S PROTECTED HEALTH INFORMATION IN
CARRYING OUT TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS AS
FOLLOWS:
I REQUEST THAT DEPARTMENT OF HEALTH CARE SERVICES RESTRICT THE USE
AND DISCLOSURE OF PROTECTED HEALTH INFORMATION TO THE FOLLOWING
PERSONS:
[PLEASE PROVIDE THE NAMES AND RELATIONSHIP OF ANY FAMILY MEMBERS,
RELATIVES, OR OTHER IDENTIFIED PERSONS TO WHOM YOU DO NOT WANT DHS TO
DISCLOSE INFORMATION.]
IDENTIFYING INFORMATION
COPY OF IDENTIFICATION ATTACHED
TYPE:__________________________ (CA DRIVER’S LICENSE, CA DMV IDENTIFICATION
CARD, STATE OR FEDERAL EMPLOYEE ID CARD)
NUMBER:__________________________
DHCS 6241a (11/07)
Page 2 of 3
I UNDERSTAND THE DEPARTMENT OF HEALTH CARE SERVICES MAY NOT AGREE TO
REQUESTED RESTRICTION(S), BUT WILL NOTIFY ME OF ITS RESPONSE TO MY REQUEST.
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:
ADDRESS VERIFICATION ATTACHED
FORM OF ADDRESS VERIFICATION _____________________________ (UTILITY BILL,
PHONE BILL, DRIVER’S LICENSE, ETC.)
DHCS 6241a (11/07)
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