Form DHCS6245A "Request for an Accounting of Disclosures of Protected Health Information by Parent, Guardian or Legal Representative (Sacramento Regional Office)" - City of Sacramento, 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 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 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 (Sacramento Regional Office)" - City of Sacramento, California

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STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
D
EPARTMENT 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 client’s 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
Sacramento Regional Office
MS 8105
1515 K Street, Room 400
P.O. Box 997413
Sacramento, CA 95899-7413
(916) 327-3100
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:
DAYTIME
EVENING
EMAIL ADDRESS:
BEST HOURS TO
TELEPHONE
TELEPHONE
REACH YOU:
NUMBER:
NUMBER:
(
)
(
)
DHCS 6245a (11/07)
Page 1 of 3
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
D
EPARTMENT 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 client’s 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
Sacramento Regional Office
MS 8105
1515 K Street, Room 400
P.O. Box 997413
Sacramento, CA 95899-7413
(916) 327-3100
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:
DAYTIME
EVENING
EMAIL ADDRESS:
BEST HOURS TO
TELEPHONE
TELEPHONE
REACH YOU:
NUMBER:
NUMBER:
(
)
(
)
DHCS 6245a (11/07)
Page 1 of 3
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.
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:
DHCS 6245a (11/07)
Page 2 of 3
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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