Health Insurance Information - California Children'S Services Page 2
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2PRIVACY STATEMENT
The information on this form is required by the county and state California Children’s Services
(CCS) as part of your application for assistance, as CCS cannot pay for that portion of expenses
which are a benefit of your insurance resource. The information is maintained pursuant to
Section 123800, et seq., of the California Health and Safety Code. You are required to provide
the information on this form. If you do not provide this information, eligibility for services may be
denied. Any information which you provide may be used by county and state CCS offices, the
California Department of Health Care Services, and providers of services. You have a right to
review records maintained by CCS concerning you. If you wish to review these records,
contact the person responsible for the records in your county CCS office. Appeals may
be directed to: Branch Chief, Children’s Medical Services (CMS) Branch, MS 8100, P.O.
Box 997413, Sacramento, CA 95899-7413 (telephone (916) 327-1400). After reviewing your
records you may request in writing that they be corrected or amended to make them
accurate, relevent, and complete.
MC 2600 (09/07)
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