Get Confidential Communication Request. Dhcs 6235a Ncro

The CONFIDENTIAL COMMUNICATION REQUEST. DHCS 6235a NCRO is an important form for individuals wishing to ensure their privacy when communicating with the Department of Health Care Services. This guide will help you navigate the process of completing this form effectively and accurately.

Follow the steps to complete the form successfully.

1. Click the 'Get Form' button to obtain the form and access it in the online editor.
2. Fill in your personal information in the 'INDIVIDUAL INFORMATION' section, including your last name, first name, and middle initial, if applicable. Ensure that your current address, city, state, and ZIP code are accurately entered.
3. Provide your Client Index Number (CIN), daytime and evening telephone numbers, date of birth, and email address. It's vital to include accurate contact information for effective communication.
4. In the statement regarding your preferred contact method, indicate that you wish to be contacted at a different address and/or telephone number for safety reasons. Provide the alternate street address or post office box, city, state, and ZIP code.
5. Specify the preferred method of contact by checking the appropriate option: 'only by telephone' or 'only by mail.' This informs the department of your communication preferences.
6. Attach a copy of your identification in the 'IDENTIFYING INFORMATION' section. Indicate the type of identification (e.g., CA driver's license, birth certificate) and provide the identification number.
7. Sign the form in the designated area, declaring that the information provided is true and correct under penalty of perjury. If identification is not attached, your signature must be notarized.
8. If required, provide notarization details, including the notary's signature and number, as well as the date of notarization.
9. Attach any necessary address verification documents, indicating the type of verification provided (e.g., utility bill, telephone bill).
10. Review the completed form for accuracy and clarity. Once satisfied, save your changes, download the form, and print or share it as necessary.

Start filling out your CONFIDENTIAL COMMUNICATION REQUEST online today!