Privacy Forms

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

General Forms

•  Privacy Complaint (DHCS 6242)
•  Whistleblower Complaint (DHCS 6243)

Medi-Cal Forms

• Access to PHI-Individual 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) (For Name or Address amendments contact the county in which eligibility was established)
• 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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Links on this page are documents in Adobe Acrobat Portable Document Format (PDF).