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​​​​​Medical Exemption Request Documentation

You have the right to inspect, review, and receive a copy of your Medical Exemption Request (MER) documentation.  You must be the individual, or the parent, guardian, or personal representative of the individual for whom you seek documentation. To request documentation of your Medical Exemption Request documents, please use the links below to download the request form.
 
Click on the appropriate link below to download the fillable request form.  After completion of the form, you can email the form to the Managed Care Quality & Monitoring Division, State Hearing Unit, or you can mail to the address listed on the form.
 

Individuals

Click this link if you are requesting the information for yourself:  DHCS 6236 Request for Access to Protected Health Information - Individuals
 

Parent, Guardian, or Personal Representative

Click this link if you are the parent, guardian, or personal representative: DHCS 6237 Request for Access to Protected Health Information - Parents, Guardians or Personal Representatives​
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Last modified date: 5/23/2022 9:16 AM