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DHCS6242 6242 0120

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State of California
Health and Human Services Agency Department of Health Care Services
DHCS 6242 (Rev. 01/20) Page 1 of 4
PRIVACY COMPLAINT FORM
File Number: _________________
Anyone may report suspected violation of HIPAA or a violation of DHCS’ privacy policies and
procedures by DHCS, DHCS staff, or a business associate of DHCS. DHCS will not intimidate,
threaten, coerce, discriminate against, or take other retaliatory action against any individual, including
DHCS employees, or business associate for filing a complaint. The information you provide here will
remain confidential to the extent possible. DHCS may need to share the information you provide to
investigate your complaint. You may submit your complaint to either the Department of Health Care
Services and/or to the U.S. Department of Health and Human Services.
Mail this completed form to:
Privacy Officer
Department of Healthcare Services
C/O Office of Legal Services
P.O. Box 997413
MS 0010
Sacramento, CA 95899-7413
You may file a complaint with the secretary of
DHHS at:
Secretary of the Department of Health and
Human Services
U.S. Office for Civil Rights
50 United Nations Plaza, Room 322
San Francisco, CA 94102
Individual Information
Last Name:
First Name: Middle Initial:
Address:
City/State: Zip Code:
Benefits ID Number:
Date of Birth:
Telephone Number:
E-mail Address:
Consent To Disclose Your Name
Please select one of the following:
☐ I consent to my name being disclosed to investigate this complaint.
☐ I do not consent to my name being disclosed.
Note: Not using your name may hinder our ability to complete the investigation.
File Number:
I
consent
to
my
name
being
disclosed
to
investigate
this
complaint.
I
do
not
consent
to
my
name
being
disclosed.
File Number:
I
consent
to
my
name
being
disclosed
to
investigate
this
complaint.
I
do
not
consent
to
my
name
being
disclosed.
State of California
Health and Human Services Agency Department of Health Care Services
DHCS 6242 (Rev. 01/20) Page 2 of 4
Information About Your Complaint
Name of the organization your
complain is against:
Name of the person(s) your
complaint is against:
Date(s) action(s) occurred:
Details of the complaint:
I have reason to believe that one or more of the following has occurred:
☐ The organization/person has inappropriately disclosed my protected health information.
☐ The organization/person has inappropriately used my protected health information.
☐ The organization/person has inappropriately disposed of my protected health information without
protecting my privacy.
☐ The organization/person has denied access to my protected health information.
☐ The organization/person has denied my request to amend my protected health information.
☐ The organization/person has denied another privacy right.
☐
The organization’s privacy policies and procedures violate the law.
Please provide a detailed description of your complaint covering what, when, who, how, where, and
why. You may attach additional pages if there is not enough space here.
Date(s) action(s)
occurred:
Name of the organization your
complain is against:
Name of the person(s) your
complaint is against:
The
organization/person
has
inappropriately
disclosed
my
protected
health
information.
The
organization/person
has
inappropriately
used
my
protected
health
information.
The
organization/person
has
inappropriately
disposed
of
my
protected
health
information
without
protecting
my
privacy.
The
organization/person
has
denied
access
to
my
protected
health
information.
The
organization/person
has
denied
my
request
to
amend
my
protected
health
information.
The
organization/person
has
denied
another
privacy
right.
The
organization’s
privacy
policies
and
procedures
violate
the
law.
Please provide a detailed
description of your complaint
covering what, when, who,
how, where, and why. You may
attach additional pages if there
is not enough space here.
Date(s) action(s)
occurred:
Name of the organization your
complain is against:
Name of the person(s) your
complaint is against:
The
organization/person
has
inappropriately
disclosed
my
protected
health
information
The
organization/person
has
inappropriately
used
my
protected
health
information
The
organization/person
has
inappropriately
disposed
of
my
protected
health
information
without
protecting
my
privacy
The
organization/person
has
denied
access
to
my
protected
health
information
The
organization/person
has
denied
my
request
to
amend
my
protected
health
information
The
organization/person
has
denied
another
privacy
right
The
organizations
privacy
policies
and
procedures
violate
the
law
Please provide a detailed description of your complaint
covering what when who how where and why You may
attach additional pages if there is not enough space here.
State of California
Health and Human Services Agency Department of Health Care Services
DHCS 6242 (Rev. 01/20) Page 3 of 4
Do you have a witness or witnesses?
☐ Yes ☐ No
If yes, please provide the names, addresses, and telephone numbers of your witnesses below:
Witness Name:
Address: Telephone Number:
Witness Name:
Address: Telephone Number:
Witness Name:
Address: Telephone Number:
RESOLUTION OF YOUR COMPLAINT
Please describe how you believe that your privacy complaint could be resolved:
Yes No
Please describe how you believe that your
privacy complaint could be resolved:
No
Yes
Please describe how you believe that your
privacy complaint could be resolved:
State of California
Health and Human Services Agency Department of Health Care Services
DHCS 6242 (Rev. 01/20) Page 4 of 4
MEDI-CAL STATUS
Are you a Medi-Cal beneficiary? ☐ Yes ☐ No
Are you enrolled in the Genetically Handicapped Persons Program (GHPP) or the California
Children’s Services (CCS) program?
☐
Yes
☐
No
CONSENT TO REFER YOUR COMPLAINT TO ANOTHER ORGANIZATION
DHCS may decide that your complaint does not violate HIPAA or DHCS’ privacy policies and
procedures. However, DHCS may determine that another organization may be able to help you.
If DHCS determines that another organization may be able to help you, please select one of the
following:
☐ I agree to have this complaint sent to another organization.
☐
I do not agree to have this complaint sent to another organization.
I DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION ON THIS FORM IS
TRUE AND CORRECT.
Your Signature:
Date:
Yes No
Are you enrolled in the Genetically Handicapped Persons Program (GHPP) or the
California Children’s Services (CCS) program?
Yes No
I
agree
to
have
this
complaint
sent
to
another
organization.
I
do
not
agree
to
have
this
complaint
sent
to
another
organization.
Your Signature: Date
Are you a Medi-Cal beneficiary?
Yes
Are you enrolled in the Genetically Handicapped Persons
Program (GHPP) or the California Children’s Services (CCS)
program?
Yes
I
agree
to
have
this
complaint
sent
to
another
organization.
I
do
not
agree
to
have
this
complaint
sent
to
another
organization.
I DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION ON THIS
FORM IS TRUE AND CORRECT.
Your Signature:
Date:
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DHCS6242 6242 0120

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Completed 3 July 2020

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