Form Dhcs 6237 - California Request To Access Protected Health Information By Parent, Guardian Or Personal Representative - Health And Human Services Agency

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STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
PRIVACY OFFICE
REQUEST TO ACCESS PROTECTED HEALTH INFORMATION
BY PARENT, GUARDIAN OR PERSONAL REPRESENTATIVE
File Number: __________________
As a parent, guardian, or personal representative you have the right to inspect the Medi-Cal records of the individual
you are authorized to represent. You also have the right to request copies of the records. 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 license or other listed identification and documentation verifying your
authority to represent the stated individual. You will also need to send documentation verifying your address, such as
a utility bill displaying your address. Mail this completed form to:
Department of Health Care Services
DHCS/MEDI-CAL FI
P. O. Box 526018
Sacramento, CA 95852-6018
(916) 636-1980
INDIVIDUAL WHOSE INFORMATION YOU ARE REQUESTING
LAST NAME
FIRST NAME
MIDDLE
INITIAL
ADDRESS
CITY/STATE
ZIP CODE
BENEFICIARY ID NUMBER
DATE OF BIRTH
DATE OF DEATH
(If applicable)
DEATH CERTIFICATE
MUST BE ATTACHED
DIRECTIONS
Please read the following before completing this form. If any of the circumstances below
applies to the beneficiary you are requesting information about, you may not need to fill out
this form.
S/He has a personal injury case and Medi-Cal has paid for services related to the injury and you
want information about these services and/or payments, or
You are requesting access to records on behalf of a deceased Medi-Cal beneficiary in order to
repay Medi-Cal for services received by the deceased beneficiary. You may have received an
Estate Recovery Questionnaire in the mail, or
S/He is involved in a worker’s compensation case in which Medi-Cal has paid for services for the
injury s/he received while on the job.
Please call (916) 650-0490 for further information. If none of these circumstances apply, please
complete the form.
DHCS 6237 (12/16)
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