Fillable Request For Access To Protected Health Information You (Department of Health Care Services)

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Request For Access To Protected Health Information You (Department of Health Care Services)

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Page 1 of 3
Request For Access To Protected Health Information
You have the right to request to inspect your Protected Health Information (PHI) in
records, which Medi-Cal Dental maintains. You also have the right to request copies of
those records. You may be charged for the cost of copying and postage. You will
receive a response to your request within 30 days after we receive your request. You
will need to send us a photocopy of your California driver’s license, Department of Motor
Vehicles Identification Card, or other valid identification. You will also need to send
documentation verifying your address. Mail this completed form to:
Medi-Cal Dental Program
Attn: HIPAA Privacy Contact
P.O. Box 15539
Sacramento, CA 95852-1539
(800) 322-6384
MEMBER INFORMATION
LAST NAME: FIRST NAME: MIDDLE
INITIAL:
ADDRESS: CITY/STATE: ZIP CODE:
BENEFITS ID NUMBER: DATE OF BIRTH:
DAYTIME
TELEPHONE
NUMBER
EVENING
TELEPHONE
NUMBER
EMAIL ADDRESS BEST HOURS
TO REACH
YOU
I-INS-FRM-008.A
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Page 2 of 3
Request For Access To Protected Health Information
PROTECTED HEALTH INFORMATION YOU WANT TO ACCESS
WHAT TYPE OF PROTECTED HEALTH INFORMATION DO YOU WANT TO
ACCESS?
SUMMARY OF PAYMENTS MADE BY MEDI-CAL DENTAL
(CLAIM DETAIL REPORT)
TREATMENT AUTHORIZATION REQUESTS
PLEASE BE SPECIFIC AS YOU MAY BE CHARGED FOR EACH PAGE
COPIED.
FOR WHAT TIME PERIOD DO YOU WANT INFORMATION?
FROM DATE TO DATE
METHOD TO ACCESS YOUR PROTECTED HEALTH INFORMATION
PLEASE MAIL ME A COPY OF THE REQUESTED INFORMATION TO THE
ADDRESS INDICATED ON PAGE ONE OF THIS FORM.
I WISH TO REVIEW THE REQUESTED INFORMATION IN PERSON.
I REQUEST THAT A PERSON OF MY CHOOSING BE ALLOWED TO
INSPECT MY RECORDS.
NAME:
TELEPHONE NUMBER:
ADDRESS:
RELATIONSHIP TO YOU:
IF YOU REQUEST TO REVIEW RECORDS IN PERSON YOU WILL BE
CONTACTED TO SCHEDULE AN APPOINTMENT.
I-INS-FRM-008.A
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Page 3 of 3
Request For Access To Protected Health Information
IDENTIFYING INFORMATION
COPY OF IDENTIFICATION ATTACHED
(PLEASE CHECK TYPE OF IDENTIFICATION)
CA DRIVER’S LICENSE CA DMV IDENTIFICATION CARD BIRTH
CERTIFICATE BENEFITS IDENTIFICATION CARD MANAGED CARE
CARD STATE OR FEDERAL EMPLOYEE ID CARD
IDENTIFICATION NUMBER:
I UNDERSTAND MEDI-CAL DENTAL MAY NOT AGREE TO REQUESTED
RESTRICTION(S), BUT WILL NOTIFY ME OF ITS RESPONSE TO MY
REQUEST.
I DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION ON
THIS FORM IS TRUE AND CORRECT.
MEMBER SIGNATURE: DATE:
(IF NO IDENTIFICATION IS ATTACHED, YOUR SIGNATURE MUST BE
NOTARIZED.)
NOTARIZED BY: ON: (DATE)
NOTARY PUBLIC NUMBER:
UNOFFICIAL UNLESS STAMPED BY NOTARY PUBLIC
ADDRESS VERIFICATION ATTACHED
(PLEASE CHECK OR FILL IN FORM OF ADDRESS VERIFICATION)
UTILITY BILL PHONE BILL DRIVER’S LICENSE OTHER
NOTE: ANY ATTEMPT TO FALSELY GAIN ACCESS TO PROTECTED HEALTH
INFORMATION IS SUBJECT TO LEGAL PENALTIES.
Medi-Cal Dental is committed to protecting the information you provide us. To prevent
unauthorized access or disclosure, to maintain data accuracy, and to ensure the
appropriate use of the information, Medi-Cal Dental has in place appropriate physical
and managerial procedures to safeguard the information we collect.
I-INS-FRM-008.A
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Request For Access To Protected Health Information You (Department of Health Care Services)

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Completed 29 December 2021

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