Get Dhs 6241a Ncro. Request To Restrict Use And Disclosure Of Protected Health Informaiton By Parent

The DHS 6241a NCRO form allows individuals to request restrictions on the use and disclosure of protected health information related to California Children’s Services. This guide provides a detailed step-by-step process to ensure users can effectively complete this online form.

Follow the steps to successfully complete the form online.

1. Click the ‘Get Form’ button to obtain the DHS 6241a NCRO form and open it in your document editor.
2. In the first section, enter the file number if applicable. This is used for tracking your request.
3. Fill in the client's information, including last name, first name, middle initial, address, city/state, ZIP code, client index number (CIN), date of birth, and date of death (if applicable). Ensure accuracy in this section as it identifies the individual for whom you are requesting restrictions.
4. Complete the parent, guardian, or legal representative information section. Include your last name, first name, middle initial, address, city/state, ZIP code, daytime and evening telephone numbers, email address, and the best hours to reach you.
5. Specify the legal authority you have to restrict the health information of the client. Check the applicable box indicating whether you are the parent, conservator, guardian, executor of a will, or hold a medical power of attorney.
6. Attach the legal documentation verifying your authority as specified in the previous step.
7. State your request regarding the restriction of the client's protected health information. Clearly outline whether you wish to restrict information related to treatment, payment, or healthcare operations.
8. List the names and relationships of any family members, relatives, or others to whom you do not want disclosure of the client's information.
9. Indicate the type of identification you are attaching to the form and provide the identification number. A photocopy must accompany the completed form.
10. Sign and date the form. If no identification is attached, ensure that your signature is notarized.
11. Finally, attach any necessary address verification documents, such as utility bills or other official correspondence, before submitting the form.
12. Once all fields are filled out accurately and required documents are attached, you may save your changes, download the completed form, print, or share it as necessary.

Begin filling out the DHS 6241a NCRO form online to request restrictions on protected health information today.