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Get Request For An Accounting Of Disclosures Of Pi - California ... - Cdph Ca
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How to fill out the Request For An Accounting Of Disclosures Of PI - California online
Filling out the Request For An Accounting Of Disclosures Of Personal Information form is a critical step in understanding how your information has been shared. This guide will assist you in completing the form accurately and submitting it online for your records responsibly.
Follow the steps to complete your request effectively.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Fill in your personal information in the designated fields. This includes your last name, first name, middle initial, address, city/state, ZIP code, beneficiary ID number, date of birth, daytime telephone number, evening telephone number, email address, and the best hours to reach you.
- Indicate which California Department of Public Health program you are requesting an accounting of disclosures from. Options are provided, and if your program is not listed, you can specify it in the designated area.
- Specify the date range for which you are requesting an accounting of disclosures. Ensure you clearly state the 'from date' and 'to date' as these are required for processing.
- Select how you wish to receive the accounting — by mail or fax. If you opt for fax, include the fax number.
- If you want someone else to receive a copy of the accounting, fill in their name, telephone number, address, and your relationship to them.
- Provide the necessary documentation verification. Attach a copy of your identification and any address verification documents.
- Review and sign the declaration affirming the information provided is true. Also, include the date of signing.
- Once all information is complete and verified, save your changes, and choose to download, print, or share the form as necessary.
Take action now to complete your documents online efficiently.
Part I - “Patient Information”: Records the patient's full name (last, first, and middle), CDCR number, date of birth, and address if he/she is paroled or released (incarcerated patients do not need to provide an address).
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