​​​​​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.

Access to Protected Health Information

• Request for Access to Protected Health Information-Individual Request (DHCS 6236)
• Request for Access to Protected Health Information by Parent, Guardian, or Personal Representative (DHCS 6237)
• Authorization for Release of Protected Health Information to Third Parties (DHCS 6247)
  

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)
  ​
  

Back to Privacy Office Home Page

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