Fillable PRIVACY COMPLAINT BY A PARENT, GUARDIAN, OR AUTHORIZED (Covered California)

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PRIVACY COMPLAINT BY A PARENT, GUARDIAN, OR AUTHORIZED (Covered California)

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STATE OF CALIFORNIA
CALIFORNIA HEALTH BENEFIT EXCHANGE/COVERED CALIFORNIA (Exchange/CC)
PRIVACY COMPLAINT BY A PARENT, GUARDIAN, OR AUTHORIZED REPRESENTATIVE
HBEX 406 (8/15)
Privacy Complaint Form
by a Parent, Guardian, or Authorized Representative
You have the right, as the consumer’s Authorized Representative to file a privacy complaint on behalf of the
consumer with Covered California. This Privacy Complaint Form is to be used to report issues related to
the consumer’s privacy. Covered California may need to share this information with outside entities in order
to investigate and resolve this complaint. Anyone may file a complaint. To submit this request, please
complete all necessary items and mail the completed form and all relevant documents to:
Consumer Information
(As indicated on your Covered California Account)
Last Name:
First Name:
Middle Initial:
Address:
City/State:
Zip Code:
Covered California Case or Account Number:
Date of Birth:
Parent, Guardian, or Authorized Representative’s Information
Last Name:
First Name:
Address:
City/State:
Daytime Phone Number (Required)
Email Address:
What legal authority do you have to act on behalf of the Consumer?
(Please attached legal documentation.)
Parent
Conservator
Executor of Will
Guardian
Agent of Health Care
Power of Attorney
Other
Privacy Officer
1601 Exposition Blvd.
Sacramento, CA 95815
PRIVACY COMPLAINT BY A PARENT, GUARDIAN, OR AUTHORIZED REPRESENTATIVE
HBEX 406 (8/15)
Page 2
Attached Copy of Representative’s Identifying Information.
(If no identifying document is attached, your signature must be notarized.)
Driver’s License
State Identification Card
Federal Issued Identification Card
Notary
Date Notarized:
UNOFFICIAL UNLESS STAMPED BY NOTARY
PUBLIC
Notarized By:
Notary Public Number:
Describe The Nature Of The Complaint
I have reason to believe that one or more of the following has occurred:
The organization/person has inappropriately disclosed their personal information.
The organization/person has inappropriately used their personal information.
The organization/person has inappropriately disposed their personal information.
The organization/person has denied access to their personal information.
The organization/person has denied their request to amend personal information.
The organization/person has denied another privacy right.
The organization’s Privacy Policies or Procedures violate the law.
Consent To Refer This Compliant To Another Organization
Covered California may have to refer this complaint to another organization. Please choose one of the
following.
I agree to have this compliant sent to another organization.
I do not agree to have this complaint sent to another organization.
PRIVACY COMPLAINT BY A PARENT, GUARDIAN, OR AUTHORIZED REPRESENTATIVE
HBEX 406 (8/15)
Page 3
Consent To Disclose Name
Please select one of the following options. (Please note, not using your name may hinder Covered
California’s ability to resolve your complaint.)
I consent to my name being disclosed in order to resolve this complaint.
I do not consent to my name being disclosed.
Please provide details of your complaint (If necessary, attach a separate page):
Signature
I understand Covered California may not be able to comply with my request, but will respond to my request.
I declare under penalty of perjury that the information on this form is true and correct.
Signature:
Date:
The information requested on this form is required by the California Health Benefits Exchange, Privacy
Office in order to process your request. The information you provide on this form is required to process your
request and will be used by the Privacy Office for that purpose. Failure to provide this information may
result in the denial of your request. Legal references authorizing the collection or maintenance of the
information provided on this form include Sections 1798.22, 1798.25, 1798.27 and 1798.35 of the California
Civil Code and Section 155.260(a) of the Code of Federal Regulations. California Health Benefits
Exchange, Privacy Office, 1601 Exposition Blvd, Sacramento, CA 95815 (800) 889-3871.
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PRIVACY COMPLAINT BY A PARENT, GUARDIAN, OR AUTHORIZED (Covered California)

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Completed 19 May 2021

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