Northern California Regional Office / San Francisco

Item Title	Number	Language	Date	Type
Confidential Communication Request	DHCS 6235a	English	11-07	Form
Request to Access Protected Health Information	DHCS 6236a	English	11-07	Form
Request to Access Protected Health Information by Parent, Guardian or Legal Representative	DHCS 6237a	English	11-07	Form
Request to Amend Protected Health Information	DHCS 6238a	English	11-07	Form
Request to Amend Protected Health Information by Parent, Guardian or Legal Representative	DHCS 6239a	English	11-07	Form
Request to Restrict Use and Disclosure of Protected Health Information	DHCS 6240a	English	11-07	Form
Request to Restrict Use and Disclosure of Protected Health Information by Parent, Guardian or Legal Representative	DHCS 6241a	English	11-07	Form
Request for an Accounting of Disclosures of Protected Health Information	DHCS 6244a	English	11-07	Form
Request for an Accounting of Disclosures of Protected Health Information by Parent, Guardian or Legal Representative	DHCS 6245a	English	11-07	Form
Authorization for Release of Protected Health Information	DHCS 6247	English	11-07	Form

Last modified on: 10/24/2008 10:08 AM

California Department of Healthcare Services