The following privacy forms help individuals access their protected health information and exercise other privacy rights. These are the Health Information Portability and accountability Act (HIPAA) forms used by DHCS.

Access to Protected Health Information

• Authorization for Release of Protected Health Information (DHCS 6236)
• Autorización Para La Divulgación De Información Médica Protegida (DHCS 6236 – Spanish)

Other Privacy Forms

• Privacy Complaint Form (DHCS 6242)
• Request for an Accounting of Disclosures of Protected Health Information (DHCS 6244)
• Request for an Accounting of Disclosures by Parent, Guardian or Personal Representative (DHCS 6245)
• Request to Amend Protected Health Information (DHCS 6238) (For Name or Address amendments contact the county in which eligibility was established)
• Request to Amend Protected Health Information by Parent, Guardian or Personal Representative (DHCS 6239)
• Confidential Communication Request (DHCS 6235)
• Request to Restrict Use and Disclosure of Protected Health Information (DHCS 6240)
• Request to Restrict Use and Disclosure of Protected Health Information by Parent, Guardian or Personal Representative (DHCS 6241)

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