Get Request To Amend Protected Health Information By Parent, Guardian Or Legal Representative. Dhcs

Filling out the request to amend protected health information can seem overwhelming, but this guide provides clear instructions to make the process easier. By following these steps, you will be able to complete the form accurately and efficiently.

Follow the steps to complete your amendment request.

1. Press the ‘Get Form’ button to retrieve the form and open it in your editor.
2. Fill in the client’s identifying information, including their last name, first name, address, city, state, client index number, date of birth, middle initial, and zip code. If applicable, include the date of death.
3. Enter the details for the parent, guardian, or legal representative completing the form. Include their last name, first name, address, city, state, middle initial, and zip code. Also, provide daytime and evening telephone numbers, email address, and the best hours to reach them.
4. Indicate the legal authority under which you are making this request by selecting one of the options: parent, conservator, guardian, executor of will, medical power of attorney, or other. Remember to attach legal documentation verifying your authority.
5. Identify the protected health information you wish to amend in the client's CCS record and specify what you want the record to state now. If necessary, attach additional paper.
6. State the reason you believe the amendment is needed to support your request.
7. Provide the names and addresses of the individuals to whom you want the CCS program to send the amended information upon approval.
8. Attach a copy of your identification. Indicate the type of identification, such as CA driver’s license, and provide the identification number. If no identification is attached, ensure your signature is notarized.
9. Sign and date the form, confirming that all information provided is true and correct. If notarized, include notary details.
10. Once completed, save changes and proceed to download, print, or share the form as needed.

Begin your journey to amend protected health information online today.