Get Request For Access To Protected Health Information - Department Of ... - Dhcs Ca

This guide provides clear and comprehensive instructions on filling out the Request For Access To Protected Health Information form from the Department of Health Care Services in California. Understanding the process will help you effectively request access to your protected health information.

Follow the steps to successfully complete your request.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Fill in your identifying information in the form, including your last name, first name, middle initial, address, city/state, zip code, benefits ID number, date of birth, daytime phone number, evening phone number, email address, and the best hours to reach you.
3. Review the directions on the form to determine if you need to fill it out. If you fall under any specific categories, such as having a personal injury case, you may not need this form.
4. Indicate what type of protected health information you wish to access by selecting options such as claim detail reports, treatment authorization request screens, or case management records.
5. Specify the dates of service for which you are requesting records by entering the from date and to date in the designated fields.
6. Choose whether you want the requested information mailed to you or if you wish to review the information in person. If reviewing in person, be prepared to schedule an appointment in Sacramento.
7. If you wish to authorize another person to inspect your records, provide their name, telephone number, address, and relationship to you.
8. Attach proof of identification and address verification as required. Include a photocopy of your valid ID and a document verifying your address or have your signature notarized if you do not provide an ID.
9. Sign and date the form, affirming that the information provided is true and correct under penalty of perjury.
10. Review all filled sections for accuracy. Save your changes, download, print, or share the completed form as needed.

Start your documentation process online now and ensure you have access to your important health information.