Page 2 of 2
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: www.caloptima.org, 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.
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
SUBMIT TO CALOPTIMA: