Form DHCS6240A "Request to Restrict Use and Disclosure of Protected Health Information (Northern California Regional Office/San Francisco)" - City and County of San Francisco, California

What Is Form DHCS6240A?

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 and County of San Francisco. 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;

Download a fillable version of Form DHCS6240A 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 DHCS6240A "Request to Restrict Use and Disclosure of Protected Health Information (Northern California Regional Office/San Francisco)" - City and County of San Francisco, California

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STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
D
EPARTMENT OF HEALTH CARE SERVICES
PRIVACY OFFICE
REQUEST TO RESTRICT USE AND DISCLOSURE
OF PROTECTED HEALTH INFORMATION
File Number: __________________
You have the right to request the Department of Health Care Services (DHCS) to restrict the use and
disclosure of your 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 your care or payment
for your 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
Northern California Regional Office/San Francisco
575 Market Street, Suite 300
San Francisco, CA 94105
(415) 904-9699
CLIENT INFORMATION
LAST NAME:
FIRST NAME:
MIDDLE
INITIAL:
ADDRESS:
CITY/STATE:
ZIP CODE:
DATE OF BIRTH:
(
):
CLIENT INDEX NUMBER
CIN
DAYTIME
EVENING
EMAIL ADDRESS:
BEST HOURS TO
TELEPHONE
TELEPHONE
REACH YOU:
NUMBER:
NUMBER:
(
)
(
)
CHECK ALL THAT APPLY
I REQUEST THAT THE DEPARTMENT OF HEALTH CARE SERVICES RESTRICT USE
AND DISCLOSURE OF MY CCS PROTECTED HEALTH INFORMATION IN CARRYING OUT
TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS AS FOLLOWS:
DHCS 6240a (11/07)
Page 1 of 2
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
D
EPARTMENT OF HEALTH CARE SERVICES
PRIVACY OFFICE
REQUEST TO RESTRICT USE AND DISCLOSURE
OF PROTECTED HEALTH INFORMATION
File Number: __________________
You have the right to request the Department of Health Care Services (DHCS) to restrict the use and
disclosure of your 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 your care or payment
for your 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
Northern California Regional Office/San Francisco
575 Market Street, Suite 300
San Francisco, CA 94105
(415) 904-9699
CLIENT INFORMATION
LAST NAME:
FIRST NAME:
MIDDLE
INITIAL:
ADDRESS:
CITY/STATE:
ZIP CODE:
DATE OF BIRTH:
(
):
CLIENT INDEX NUMBER
CIN
DAYTIME
EVENING
EMAIL ADDRESS:
BEST HOURS TO
TELEPHONE
TELEPHONE
REACH YOU:
NUMBER:
NUMBER:
(
)
(
)
CHECK ALL THAT APPLY
I REQUEST THAT THE DEPARTMENT OF HEALTH CARE SERVICES RESTRICT USE
AND DISCLOSURE OF MY CCS PROTECTED HEALTH INFORMATION IN CARRYING OUT
TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS AS FOLLOWS:
DHCS 6240a (11/07)
Page 1 of 2
I REQUEST THAT THE DEPARTMENT OF HEALTH CARE SERVICES RESTRICT THE USE
AND DISCLOSURE OF THE CCS 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 DHCS 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:__________________________
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.
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.)
DHCS 6240a (11/07)
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