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

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

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

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File type: PDF

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STATE OF CALIFORNIA
CALIFORNIA HEALTH BENEFIT EXCHANGE/COVERED CALIFORNIA (Exchange/CC)
REQUEST FOR AN ACCOUNTING OF DISCLOSURES OF YOUR PERSONAL INFROMATION
HBEX 407 (9/15)
Request for an Accounting of Disclosures of Your Personal Information
You have the right to request Covered California provide an accounting of any disclosures made to external
entities pertaining to your 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 Account Number:
Date of Birth:
Daytime Phone Number:
Email Address
Address Verification
(Please attached a copy of one of the following with your name and current address.)
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:
Privacy Officer
1601 Exposition Blvd.
Sacramento, CA 95815
REQUEST FOR AN ACCOUNTING OF DISCLOSURES OF YOUR PERSONAL INFROMATION
HBEX 407 (9/15)
Page 2
Signature
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?
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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REQUEST FOR AN ACCOUNTING OF DISCLOSURES OF YOUR (Covered California)

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Completed 19 May 2021

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