MCAL MM18–98_DHCS Approved 01.29.19_Accounting of Disclosures
Page 1 of 2
Request for an Accounting of Disclosures Form
Date of Request:
Member Name:
Member CIN:
Date of Birth:
Phone Number:
I would like a report of how my Protected Health Information (PHI) was disclosed by CalOptima, as
required by law. I understand that CalOptima does not have to tell me about the following types of
1. Disclosures for purposes of Treatment, Payment and Health Care Operations.
2. Disclosures to me or authorized by me to another person(s).
3. Disclosures to persons involved in my care.
4. Disclosures made prior to April 14, 2003.
I also understand that my right to a report of some, or all disclosures, may be suspended in some instances.
I understand that CalOptima must give me the report of disclosures within 60 days of my request, or give
notice to me that an extra 30 days (or less) is needed to prepare it.
I understand I am allowed 1 free report of disclosures every 12-months. I may be charged a fee if I ask for
more than 1 report within the same 12-months.
Please note, this is not a request for Access to Protected Health Information (PHI). You will not get
records such as Medical Claims or Pharmacy Claims by using this form. If you would like these type
of records, please fill out the Individual Request for Access to Protected Health Information in the
Designated Record Set form.
To learn more about your privacy rights, please visit our website at or call CalOptima’s
Customer Service Department toll-free at 1-888-587-8088. Members with hearing or speech impairments
can call our TDD/TTY line at 1-800-735-2929. We have staff who can speak your language.
MCAL MM18–98_DHCS Approved 01.29.19_Accounting of Disclosures
Page 2 of 2
I would like a record of disclosures that covers the following time period:
From: To:
Note: The time period may not be longer than six (6) years, and may not include dates before April
14, 2003.
Delivery method requested (select one):
Personal pick-up at CalOptima (ID required at the time of pick-up)
Address/Unit City State Zip
Electronically, sent through a secure e-mail to:
Member Signature: Date:
If Personal Representative, please complete the section below and provide documentation:
Print Name: Relationship to Member: