California Department of Healthcare Services

Privacy Forms

The following privacy forms help individuals access their their protected health information and exercise other privacy rights.  These are the official HIPAA forms used by DHCS health plans covered by HIPAA.

 Links on this page are documents in Adobe Acrobat Portable Document Format (PDF).

General Forms

•  Privacy Complaint (DHCS 6242)

Medi-Cal Forms

• Access to PHI-Indvidual Request (DHCS 6236)
• Access to PHI by Parent, Guardian or Personal Representative (DHCS 6237)
• Authorization for Release of PHI (DHCS 6247)
• Accounting of Disclosures Request (DHCS 6244)
• Accounting of Disclosures by Parent, Guardian or Personal Representative (DHCS 6245)
• Amend PHI Request (DHCS 6238)
• Amend PHI by Parent, Guardian or Personal Representative (DHCS 6239)
• Confidential Communications Request (DHCS 6235)
• Restrict Uses and Disclosures of PHI Request (DHCS 6240)
• Restrict Uses and Disclosures of PHI by Parent, Guardian or Personal Representative Request (DHCS 6241)

California Children's Services

• Northern California Regional Office / San Francisco
• Southern California Regional Office
• Sacramento Regional Office

Genetically Handicapped Persons' Program

• Various forms

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