Form Dhcs 6237 - California Request To Access Protected Health Information By Parent, Guardian Or Personal Representative - Health And Human Services Agency Page 3

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STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
PRIVACY OFFICE
METHOD TO RECEIVE YOUR PROTECTED HEALTH INFORMATION
PLEASE MAIL ME A COPY OF THE REQUESTED INFORMATION.
I WISH TO REVIEW THE REQUESTED INFORMATION IN PERSON.
IF YOU REQUEST TO REVIEW RECORDS IN PERSON, YOU WILL BE CONTACTED TO SCHEDULE AN
APPOINTMENT. LOCATION AVAILABLE FOR IN PERSON REVIEW: SACRAMENTO ONLY
I REQUEST THAT A PERSON OF MY CHOOSING BE ALLOWED TO INSPECT THE RECORDS.
NOTE: Any person or attorney may be named below. Records will not be sent to photocopy services.
NAME
TELEPHONE NUMBER (
)
ADDRESS
RELATIONSHIP TO YOU
IDENTIFYING INFORMATION IS REQUIRED
ADDRESS VERIFICATION ATTACHED
_____________________________
TYPE:
(UTILITY BILL, PHONE BILL, DRIVER’S LICENSE, ETC.)
COPY OF IDENTIFICATION ATTACHED
TYPE: __________________________ (CA DRIVER’S LICENSE, CA DMV IDENTIFICATION CARD, BIRTH
CERTIFICATE, BENEFITS IDENTIFICATION CARD, MANAGED CARE CARD, STATE OR FEDERAL EMPLOYEE ID
CARD)
NUMBER: __________________________
(IF NO IDENTIFICATION IS ATTACHED, YOUR SIGNATURE MUST BE NOTARIZED.)
NOTARIZED BY ___________________________________ ON ___________________(DATE)
NOTARY PUBLIC NUMBER ________________________________
UNOFFICIAL UNLESS STAMPED BY NOTARY PUBLIC
I DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION ON THIS FORM IS TRUE AND
CORRECT.
REPRESENTATIVE SIGNATURE
DATE
NOTE: ANY ATTEMPT TO FALSELY GAIN ACCESS TO PROTECTED HEALTH INFORMATION IS SUBJECT TO LEGAL
PENALTIES.
DHCS 6237 (12/16)
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