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Department of Health Care Services (Department of Health Care Services)

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AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH
INFORMATION TO THIRD PARTIES (DHCS 6247)
File Number: __________________
By completing this form you are authorizing the California Department of Health
Care Services to release your protected health information identified herein to the
persons or entities identified herein. You also have the right to request copies of
those records. You will receive a response to your request within 30 days after we
receive your request. If you want copies of your records mailed, you need to send
us a photocopy of your California driver’s license, Department of Motor Vehicles
Identification Card, or other valid identification. You will also need to send
documentation verifying your address. Please check the box on page three of this
document if you would also like a copy of the requested records sent to you.
Mail this completed form to address below:
Department of Health Care
Services DHCS/MEDI-CAL FI
P. O. Box 526018
Sacramento, CA 95852-6018
(916) 636-1980
Your Information
Last Name: First Name: Middle Initial:
Address:
City/State:
Zip Code:
Benefits ID Number:
Date of Birth:
Telephone Number:
E-mail Address:
DHCS 6247 (08/17) Page 1 of 5
State of
C
alifornia—Health
and Human Services A
gency
Department of Health Care Services
JENNIFER KENT
DIRECTOR
EDMUND G. BROWN JR.
GOVERNOR
Person/Organization Providing the
Information
Name: __________________________
Position or Role: __________________
Address: ________________________
City/State/Zip: ____________________
Phone # : (_____) _______ _________
Fax #: (______) ______ _______
Person/Organization to Receive the
Information
Name: __________________________
Position or Role: __________________
Address: ________________________
City/State/Zip: ____________________
Phone # : (_____) _______ _________
Fax #: (______) ______ _______
Description of the Specific Information to be Released/Inspected
Check Each Type of Confidential Information you Authorize to be Released/Inspected:
Information
HIV or AIDS Information Alcohol/Drug Information
Mental Health/Behavioral Health Genetic Testing
Other:
from_____________ (date) to_____________ (date).
Information from the categories above will be authorized for the following period of time:
Check each type of protected information you want to access:
Claim Detail Reports, which
contain claims paid by Medi-Cal for
services received.
Managed Care Records:
Enrollment Records
Disenrollment Records
Capitation Paid to Health Plan
MERS Fair Hearing Documentation
Treatment Authorization Request
Screens. Printouts contain patient
names,
which providers have requested
services, which services were
requested, the decision about the
service(s), including a simple
description of the decision, and whether
the provider has billed for these
services.
Case Management Records,
which contain case manager notes.
Denti-Cal Records:
Call (800) 322-6384
Please contact your care provider
or managed care plan if you want
access to your medical records.
DHCS 6247 (08/17) Page 2 of 5
I Am Requesting Copies of Records for the Following
Dates of Service
You must specify dates of service in order to get records.
From Date (month/day/year)
To Date (month/day/year)
Description of the Purpose and Limitations for the Release or
Inspection of the Information (Indicate how information will be used)
The information will not be used for any purpose other than its intended use.
Personal Representative Information
Last Name:
First Name:
Middle
Initial:
Address:
City/State:
Zip Code:
Telephone Number:
E-mail Address:
What Legal Authority do You Have to Request Health Information
Conservator
Executor of Will
Administrator of Estate
Other
Parent of a Minor
Guardian
Medical Power of Attorney
Note: You Must Attach Legal Documentation to Verify That You Are the
Parent, Conservator, Guardian, Executor of a Decedent’s Will, Or Have
Medical Decision-Making Authority for the Individual.
DHCS 6247 (08/17) Page 3 of 5
I DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION ON THIS FORM IS TRUE AND
CORRECT.
BENEFICIARY SIGNATURE DATE
Please note: A request for records of services provided up to six years ago is a
30-day process. All other requests require approximately 60 days for processing.
Please Mail Me A Copy of the Requested Information.
I Wish to Review the Requested Information in Person.
I Request That a Person of My Choosing be Allowed to Inspect My Records.
Note: Any person or attorney may be named below. Records will not be sent
to photocopy services.
Name.................................
Telephone Number............
Address..............................
Relationship to You............
If You Request to Review Records in Person, You Will be Contacted to Schedule
an Appointment. Location Available for in Person Review: Sacramento Only
Requestor's Identifying Information
Address Verification Attached
Type:
_____________________________ (Utility Bill, Phone Bill, Driver's License, Etc.)
Copy of Identification Attached
Type:
__________________________ (CA Driver's License, CA DMV Identification
Card, Birth Certificate, Benefits Identification Card, Managed Care Card, State
or Federal Employee ID Card)
Number:
__________________________
(IF NO IDENTIFICATION IS ATTACHED, YOUR SIGNATURE MUST BE NOTARIZED)
Notarized by
___________________________________ on ___________________(Date).
Notary Public Number ________________________________
UNOFFICIAL UNLESS STAMPED BY NOTARY PUBLIC.
DHCS 6247 (08/17) Page 4 of 5
This authorization for release of the above information to the above named
persons or organizations will expire on: ______ (specific date).
I understand that by signing this authorization:
• I authorize the use and/or disclosure of my individually identifiable health
information as described above for the purpose listed. I understand that this
authorization is voluntary.
• I have the right to revoke this authorization at any time by sending a signed notice
stopping this authorization to the address on page one. The authorization will
cease on the date my valid revocation request is received.
•
An individual may revoke an authorization at any time, provided that the
revocation is in writing, except to the extent that: The covered entity has taken
action in reliance thereon; or if the authorization was obtained as a condition of
obtaining insurance coverage.
• My treatment, payment, enrollment or eligibility for benefits will not be affected if I
do not sign this authorization.
• Under California law, the recipient of my medical information is prohibited from re-
disclosing the information, except with a written authorization or as specifically
required or permitted by law.
•
If the organization or person I have authorized to receive the information is not a
health plan or health care provider; the released information may no longer be
protected by federal privacy regulations.
• I have the right to receive a copy of this authorization.
• Records and copies obtained relating to outpatient psychotherapy care shall be
returned or destroyed at the expiration date of this authorization except those
obtained for treatment and diagnosis purposes.
I DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION ON THIS
FORM IS TRUE AND CORRECT.
Member or Personal Representative Signature: Relationship if not Member: Date:
DHCS 6247 (08/17) Page 5 of 5
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Completed 30 July 2020

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