MCAL MM-19-665_DHCS Approved 11.05.2019_HH.3007 Attachment A
Request for Restriction on Use and Disclosure of Protected Health Information (PHI)
Date of Request:
Member Name: Date of Birth:
Member CIN: Telephone Number:
I understand that CalOptima may use or disclose (release) my Protected Health Information (PHI) for the
purposes of treatment, payment, and health care operations. CalOptima may also release information to
someone involved in my care or the payment for my care, such as a family member or friend.
I understand that CalOptima does not have to agree to my request.
I request a restriction on CalOptima’s Use and Disclosure of Protected Health Information (PHI).
The information I want limited is:
I want to limit CalOptima’s:
Use of this Information
Disclosure of this information
Both the use and disclosure of this information
I want the limits to apply to the following person or entity (For example: spouse):
Even if CalOptima agrees to the restriction, the information may still be shared under the following
During a medical emergency, if the restricted information is needed to provide emergency
treatment. However, if the information is disclosed during an emergency, CalOptima will tell the
recipient not to use or disclose it for any other purpose.
For health agency oversight activities.
For uses or disclosures otherwise required by law.
CalOptima receives a written termination request.
I orally agree to the termination and the oral agreement is documented.
CalOptima informs me that it is terminating the agreement. In this case, the termination is only
effective for PHI created or received by CalOptima after I am notified of the termination.
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To learn more about your privacy rights, please refer to your copy of the CalOptima Notice of Privacy
Practices. It can also be found on our website at or by calling CalOptima’s
Customer Service Department at 1-714-246-8500 or toll-free at 1-888-587-8088. We are available
Monday through Friday from 8 a.m. to 5:30 p.m. Members with hearing or speech impairments can call
our TDD/TTY line at 1-714-246-8523 or toll-free at 1-800-735-2929. We have staff who speak your
If you believe your privacy rights have been violated, you may file a complaint with CalOptima by calling
1-714-246-8500 or write to:
Customer Service Department
505 City Parkway West
Orange, CA 92868
CalOptima cannot take away your health care benefits or do anything to hurt you in any way if you choose
to file a complaint or use any of your privacy rights.
Member Signature:
If Authorized Representative (please include legal documentation):
Print Name: Relationship to Member: