Form DHCS6238A "Request to Amend Protected Health Information - Genetically Handicapped Persons Program" - California

What Is Form DHCS6238A?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. 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 DHCS6238A 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 DHCS6238A "Request to Amend Protected Health Information - Genetically Handicapped Persons Program" - 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
File Number: __________________
You have the right to request amendments to your protected health information which the
California Children’s Services (CCS) program
Department of Health Care Services,
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
Genetically Handicapped Persons Program
1515 K Street, Room 400
MS 8100
P.O. Box 997413,
Sacramento, CA 95899-7413
(800) 639-0597
CLIENT 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 REACH
TELEPHONE
TELEPHONE
YOU:
NUMBER:
NUMBER:
(
)
(
)
PROTECTED HEALTH INFORMATION YOU WANT TO AMEND
IDENTIFY THE PROTECTED HEALTH INFORMATION IN YOUR CCS RECORD YOU WANT
AMENDED:
DHCS 6238a (11/07)
Page 1 of 3
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
PRIVACY OFFICE
REQUEST TO AMEND
PROTECTED HEALTH INFORMATION
File Number: __________________
You have the right to request amendments to your protected health information which the
California Children’s Services (CCS) program
Department of Health Care Services,
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
Genetically Handicapped Persons Program
1515 K Street, Room 400
MS 8100
P.O. Box 997413,
Sacramento, CA 95899-7413
(800) 639-0597
CLIENT 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 REACH
TELEPHONE
TELEPHONE
YOU:
NUMBER:
NUMBER:
(
)
(
)
PROTECTED HEALTH INFORMATION YOU WANT TO AMEND
IDENTIFY THE PROTECTED HEALTH INFORMATION IN YOUR CCS RECORD YOU WANT
AMENDED:
DHCS 6238a (11/07)
Page 1 of 3
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
PRIVACY OFFICE
WHAT YOU WANT THE RECORD TO STATE NOW: (ATTACH ADDITIONAL PAPER IF
NECESSARY)
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 YOUR PHI.
DHCS 6238a (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 6238a (11/07)
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