Get Pdf Fillable Form 6236

This guide provides a comprehensive overview of how to accurately fill out the Pdf Fillable Form 6236 online for accessing protected health information. By following these instructions, users can ensure a smooth process in requesting their records from the California Department of Health Services.

Follow the steps to successfully complete the form online.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred PDF editor.
2. Begin by completing the 'Individual Information' section. Provide your last name, first name, middle initial, address, city/state, zip code, benefits ID number, date of birth, and both daytime and evening telephone numbers.
3. Include your email address and specify the best hours to reach you. This information is crucial for facilitating communication regarding your request.
4. Review the directions carefully. If applicable, ensure that none of the outlined circumstances that exclude you from filling out this form apply to you.
5. On page two, indicate the type of protected health information you wish to access. Choose from claim detail reports, treatment authorization request screens, and case management records. Be sure to note any fees associated with these requests.
6. Specify the dates of service for which you are requesting copies of records by filling in the 'From' and 'To' date fields. This is essential for accurate processing.
7. Choose whether you would like the requested information mailed to you, reviewed in person at the specified location in Sacramento, or if you wish to have someone else inspect your records. Fill in their details if applicable.
8. Attach any required documentation for identification and address verification as specified in the form. Include a copy of identification if required, or ensure your signature is notarized.
9. Finally, sign and date the form to declare that the information provided is true and correct. Ensure all fields are completed accurately before proceeding.
10. After filling out the form, you can save your changes, download a copy of the form, or print it for mailing. Send the completed form to the address provided in the directions.

Complete your documents online today and ensure your request for health information is properly filed.