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MCAL MM-19-659_DHCS Approved 11.05.2019_HH.3004 Attachment A
Member Request to Amend Protected Health Information (PHI)
Date of Request:
Member Name:
Date of Birth:
Member CIN: _ Telephone Number:
Please tell us what Protected Health Information (PHI) or record you would like CalOptima to change:
Please tell us why you would like this change. You must give a reason:
CalOptima must notify you within 60 calendar days if the changes were made as you requested or tell you that
more time is needed (up to 30 calendar extra days) to decide. Please tell us where to send you a letter:
Address: Apt #:
City: State: Zip Code:
If CalOptima decides to change the record as you requested, the change will be sent to any person who received
the information before it was changed. Please tell us if there are any such persons who need the changed
Yes Please list the person’s names and addresses:
We will also send the change to other persons that we know received the information before it was changed if
they relied, or might in the future rely, on the information. Do you agree to this?
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MCAL MM-19-659_DHCS Approved 11.05.2019_HH.3004 Attachment A
CalOptima does not have to change your record if:
CalOptima did not create the information.
The information in the record is accurate and complete.
You do not have the legal right to access the Protected Health Information (PHI) you want changed.
The Protected Health Information (PHI) you want changed is not part of the information kept by
CalOptima (Member Designated Record Set; this includes enrollment information, billing records and
records containing your Protected Health Information (PHI) that are used by us to make decisions about
To learn more about your privacy rights, please refer to your copy of the CalOptima Notice of Privacy
Practices. It is also be found on our website:, or you can call the CalOptima’s Customer
Service Department at 1-714-246-8500 or toll-free at 1-888-587-8088, Monday through Friday from 8 a.m. to
5:30 p.m. Members with hearing or speech impairments can call our TDD/TTY line at 1-714-246-8523 or toll-
free at 1-800-735-2929. We have staff who can speak your language.
If you believe your privacy rights have been violated, you may file a complaint with CalOptima by calling 1-
CalOptima cannot take away your health care benefits or do anything to hurt you in any way if you choose to
file a complaint or use any of the privacy rights.
Member Signature:
If Authorized Representative (please include appropriate documentation):
Print Name: Relationship to Member:
Return this completed form to:
CalOptima Privacy Officer
505 City Parkway West
Orange, CA 92868
Fax: 714-338-3166