Form Dhcs 6237 - California Request To Access Protected Health Information By Parent, Guardian Or Personal Representative - Health And Human Services Agency Page 2

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INDIVIDUAL ABOVE?
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
PRIVACY OFFICE
PARENT, GUARDIAN, OR PERSONAL REPRESENTATIVE INFORMATION
LAST NAME
FIRST NAME
MIDDLE
INITIAL
ADDRESS
CITY/STATE
ZIP CODE
DAYTIME TELEPHONE
EVENING TELEPHONE
EMAIL ADDRESS
BEST HOURS TO REACH
NUMBER (Required)
NUMBER
YOU
(
)
(
)
WHAT LEGAL AUTHORITY DO YOU HAVE TO REQUEST HEALTH INFORMATION OF THE
PARENT
CONSERVATOR
GUARDIAN
EXECUTOR OF WILL
MEDICAL POWER OF ATTORNEY
OTHER
NOTE: YOU MUST ATTACH LEGAL DOCUMENTATION TO VERIFY THAT YOU ARE THE PARENT,
CONSERVATOR, GUARDIAN, EXECUTOR OF A DECEDENT’S WILL, OR HAVE MEDICAL DECISION-MAKING
AUTHORITY FOR THE INDIVIDUAL.
WHAT TYPE OF PROTECTED HEALTH INFORMATION DO YOU WANT TO ACCESS?
CLAIM DETAIL REPORTS, which contain claims
Managed Care Records:
paid by Medi-Cal for services received.
Enrollment Records
Disenrollment Records
TREATMENT AUTHORIZATION REQUEST
Capitation Paid to Health Plan
MERS Fair Hearing Documentation
SCREENS. Printouts contain patient names, which
providers have requested services, which services were
Denti-Cal Records:
requested, the decision about the service(s), including a
Call (800) 322-6384
simple description of the decision, and whether the
provider has billed for these services.
Please contact the managed care plan if you want access
to medical records.
CASE MANAGEMENT RECORDS, which contain
case manager notes.
I AM REQUESTING COPIES OF RECORDS FOR THE FOLLOWNG DATES OF SERVICE
You must specify dates of service in order to get records.
FROM DATE (month/day/year)
TO DATE (month/day/year)
Please note: A request for records of services provided up to 6 years ago is a 30-day process. All other requests have
a 60-day time frame for additional processing.
DHCS 6237 (12/16)
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