Fillable STATE OF CALIFORNIA DEPARTMENT OF INSURANCE HEALTH REQUEST (California)

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STATE OF CALIFORNIA DEPARTMENT OF INSURANCE HEALTH REQUEST (California)

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  • 29 check-boxes
  • 41 other fields

Country of origin: US
File type: PDF

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STATE OF CALIFORNIA
Ricardo Lara, Insurance Commissioner
DEPARTMENT OF INSURANCE
CONSUMER SERVICES AND MARKET CONDUCT BRANCH
CONSUMER SERVICES DIVISION
300 SOUTH SPRING STREET, SOUTH TOWER
LOS ANGELES, CA 90013
www.insurance.ca.gov
CSD-002-HRFA
Revised: 01/07/2019
HEALTH REQUEST FOR ASSISTANCE (HRFA)
Name Daytime Phone: ( )
Address Alternate Phone: ( )
City /Zip Email address:
Insured’s Date of Birth Insured’s Gender ☐ Male ☐ Female
===============================================================================
Name of the policyholder if different from your name:
Type of Insurance: ☐ Health ☐ Dental/Vision ☐ Medicare Supplement ☐ Other
What is the primary language spoken in your home?
In order to ensure all Californians have access to health insurance, please identify your race/ethnicity. One or
more categories may be selected
: ☐ American Indian/Alaska Native ☐ Asian
☐ Black/African American ☐ Hispanic/Latino
☐ Pacific Islander/Native Hawaiian ☐ White
☐ Decline to State
Complete name of insurance company involved: ________________________________________________
Policy number: Claim number:
Date(s) of Medical Service(s) Provided (if applicable)
Insurance Agent (if applicable) Agent License Number
Agent Phone Number: Agent Email Address:
Agent Street Address City/State / Zip
Have you contacted the company or the agent? Yes
No
If yes, state the date(s) and person(s) contacted
Have you reported this to any other governmental agency? Yes
No
Name of Agency:
Date Reported: Case Number
I
Have you previously written to the Department of Insurance about this matter? Yes No
File number (if available) Date
Are you represented by an attorney in this matter? Yes No
Has a lawsuit been filed? Yes No
Is the case currently in active litigation? Yes No If yes, we will defer the
regulatory investigation
until the
finality of the litigation. We ask that you still complete this form so we have a record of your issue. Once the matter is
concluded, we would welcome any information regarding violations of insurance law by the insurer that you or your attorney
are willing to provide.
Briefly, describe your problem (use additional paper if needed):
What do you consider to be a fair resolution to your problem?
In order for us to effectively begin our investigation, please provide any supporting documentation you may
have related to this matter along with your Health Request for Assistance (HRFA).
□ Copy of insured’s insurance identification card – both sides
□ Copies of correspondence between you and the insurance company/agent, including all related Explanation
of Benefits (EOBs)
□ If you wish to give authority to someone to assist you in filing this Health Request for Assistance (HRFA),
please complete the Authorization and Designation of Agent form.
PLEASE READ:
I understand that a copy of this form and all documentation submitted will be provided to the licensee
involved in this Health Request for Assistance.
(Signature) (Date)
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□
State of California
Department of Insurance
Authorization and Designation of Agent
•
If you want to give someone the authority to assist you in the filing of your complaint please fill in Parts A
and B below.
•
If you are a parent or legal guardian filing this complaint for a child under the age of 18, you do not need to
complete this form.
•
If you are filing a complaint for a consumer who cannot complete this form and you have legal authority to
act for this consumer, please complete Part B only. Also send a copy of the power of attorney for health
care decisions or other legal document that says you can make decisions for the consumer.
PART A: COMPLAINANT
I allow the person named below in Part B to assist me in completing a complaint filed with the California
Department of Insurance (CDI). I allow the CDI to share my personal information with the person named
below in Part B. This may include information about my medical condition(s) and care if applicable and may
include mental health treatment, HIV treatment or testing, alcohol or drug treatment, or other health care
information.
I understand that only information related to my complaint will be shared.
My approval of this assistance is voluntary and I have the right to end it. If I want it to end, I must do so in
writing.
Name of Complainant (Print)
Complainant Signature_ Date
PART B: PERSON ASSISTING THE COMPLAINANT
If Applicable, Name of Organization (Please print)
Name of Person Assisting (Please print)
Signature of Person Assisting
Address
Relationship to Complainant
Daytime Phone # Evening Phone #
My Power of Attorney for health care decisions or other legal document is attached.
Return the completed form to California Department of Insurance, Consumer Services Division, 300 S. Spring
Street, Los Angeles, CA 90013. If you have any questions, the Department can be reached at (800) 927-4357
.
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STATE OF CALIFORNIA Ricardo Lara, Insurance Commissioner
DEPARTMENT OF INSURANCE
Privacy Notice on Information Collection
Request for Assistance Forms
*** This notice is provided pursuant to the Information Practices Act of 1977 (California Civil Code Section 1798.17) ***
Collection and Use of Personal Information
California Insurance Code Sections 12921 and 12921.1, and related statutes and regulations, give the
California Department of Insurance (CDI) and the Consumer Services Division the authority to regulate and
investigate consumer complaints. The CDI uses your information to address complaints brought to the
Department’s attention. Information is collected subject to limitations contained in the Information Practices Act
of 1977, SAM 5300, et seq., SIMM 5305, et seq., and other applicable state and federal laws.
Providing Personal Information Is Voluntary
You do not have to provide the personal information requested. However, if you do not wish to provide us the
necessary information, we may not be able to investigate your complaint. When providing information or
documents, please do not include unrequested personal information, such as Social Security Numbers,
Driver’s License Numbers, unnecessary health-related information, and credit card or financial information.
Information Provided to CDI Is Confidential
All information you provide to us during the investigation of your complaint will be treated as a confidential
communication under California Insurance Code Section 12919. We will not disclose any information to any
person outside CDI, unless otherwise permitted or required by law.
Possible Disclosure of Personal Information
We may share your personal information with the insurance licensee and in the case of an Independent Medical
Review with the Independent Medical Review Organization. We may also share your information with other
government or regulatory agencies as required by law, or pursuant to Memorandum of Understanding.
Access to Your Information
You have the right to access records containing your personal information which are maintained by CDI. To
request access, contact: CDI Privacy Officer, Legal Division, Government Law Bureau, 300 Capitol Mall, Suite
1700, Sacramento, CA 95814, (916) 492-3500.
Department Privacy Policy
The California Department of Insurance has developed policies regarding the privacy of your information. They
may be viewed at www.insurance.ca.gov/privacy-policy.
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STATE OF CALIFORNIA DEPARTMENT OF INSURANCE HEALTH REQUEST (California)

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Completed 10 May 2021

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