Fillable REQUEST FOR AN ACCOUNTING OF DISCLOSURES OF PERSONAL (Covered California)

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REQUEST FOR AN ACCOUNTING OF DISCLOSURES OF PERSONAL (Covered California)

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The REQUEST FOR AN ACCOUNTING OF DISCLOSURES OF PERSONAL (Covered California) form is 2 pages long and contains:

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STATE OF CALIFORNIA
CALIFORNIA HEALTH BENEFIT EXCHANGE/COVERED CALIFORNIA (Exchange/CC)
REQUEST FOR AN ACCOUNTING OF DISCLOSURES OF PERSONAL INFROMATION BY A PARENT,
GUARDIAN, OR AUTHORIZED REPRESENTATIVE
HBEX 408 (9/15)
Request for an Accounting of Disclosures of Personal Information by a Parent, Guardian, or
Authorized Representative
As the Consumer’s Authorized Representative, you have the right to request Covered California provide an
accounting of any disclosures made to external parties pertaining to the Consumer’s Personally Identifiable
Information. We will provide one accounting a year for free but will charge a reasonable, cost-based fee if you
ask for another within 12 months. 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 Incident Number:
Date of Birth:
Parent, Guardian, or Authorized Representative’s Information
Last Name:
Middle Initial:
Address:
Zip Code:
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
REQUEST FOR AN ACCOUNTING OF DISCLOSURES OF PERSONAL INFROMATION BY A PARENT,
GUARDIAN, OR AUTHORIZED REPRESENTATIVE
HBEX 408 (9/15)
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
Other
Date Notarized:
UNOFFICIAL UNLESS STAMPED BY NOTARY
PUBLIC
Notarized By:
Notary Public Number:
Describe Your Request
I request Covered California account for the disclosure of Personally Identifiable Information
From: _(Month/Year) To: (Month/Year)
Is there a specific event Covered California should be looking for?
Authorized Representative’s Signature
I understand Covered California may not be able to comply with my request but will provide me with a response.
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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REQUEST FOR AN ACCOUNTING OF DISCLOSURES OF PERSONAL (Covered California)

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Completed 19 May 2021

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