Fillable Privacy Complaint Form PRIVACY COMPLAINT HBEX 405 (8/15) (Covered California)

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Privacy Complaint Form PRIVACY COMPLAINT HBEX 405 (8/15) (Covered California)

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The Privacy Complaint Form PRIVACY COMPLAINT HBEX 405 (8/15) (Covered California) form is 3 pages long and contains:

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STATE OF CALIFORNIA
CALIFORNIA HEALTH BENEFIT EXCHANGE/COVERED CALIFORNIA (Exchange/CC)
PRIVACY COMPLAINT
HBEX 405 (8/15)
Privacy Complaint Form
You have the right to file a privacy complaint with Covered California. This Privacy Complaint Form is to be
used to report issues related to your privacy.
Covered California may need to share your information with outside entities in order to investigate and
resolve your complaint. Anyone may file a complaint about the use of their Personally Identifiable
Information. To submit this form, please complete all necessary items and mail the completed form and all
relevant documents to:
Privacy Officer
1601 Exposition Blvd.
Sacramento, CA 95815
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:
Daytime Phone Number: Email Address
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 my personal information.
The organization/person has inappropriately used my personal information.
The organization/person has inappropriately disposed my personal information.
The organization/person has denied access to my personal information.
The organization/person has denied my request to amend personal information.
The organization/person has denied another privacy right.
The organization’s Privacy Policies or Procedures violate the law.
PRIVACY COMPLIANT
HBEX 405 (8/15)
Page 2
Please provide details of your complaint (Attach a separate sheet if necessary):
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.
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.
PRIVACY COMPLIANT
HBEX 405 (8/15)
Page 3
Address Verification
(Please attached a copy of one of the following with your name and current address.)
California Driver’s License Utility Bill Other
Identity Verification
(Please attached a copy of one of the following. If no identifying document is attached, your signature must
be notarized.)
California Driver’s License State of California Identification Card
Federal Issued I.D. Card Notary
Date Notarized:
UNOFFICIAL UNLESS STAMPED BY NOTARY
PUBLIC
Notarized By:
Notary Public Number:
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 Form PRIVACY COMPLAINT HBEX 405 (815) (Covered California)

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Completed 19 May 2021

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