​​​Privacy Forms

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

General Forms

•  Privacy Complaint (DHCS 6242)​
  

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