Privacy-HIPAA Forms
CDPH 6234 (PDF)Ā - Request for Confidential Communication
CDPH 6235 (PDF)Ā - Request for Confidential Communication of Personal Information by Parent, Guardian or Personal Representative
CDPH 6236 (PDF)Ā - Request for Access to Personal Information
CDPH 6237 (PDF)Ā - Request to Access Personal Information by Parent, Guardian or Personal Representative
CDPH 6238 (PDF)Ā - Request to Amend Personal Information
CDPH 6239 (PDF)Ā - Request to Amend Personal Information by Parent, Guardian or Personal Representative
CDPH 6240 (PDF)Ā - Request to Restrict Use and Disclosure of Personal Information
CDPH 6241 (PDF)Ā - Request to Restrict Use and Disclosure of Personal Information by Parent, Guardian or Personal Representative
CDPH 6242 (PDF)Ā - Privacy/HIPAA Complaint Form
CDPH 6244 (PDF)Ā - Request for an Accounting of Disclosures of Personal Information
CDPH 6245 (PDF)Ā - Request for an Accounting of Disclosures of Personal Information by Parent, Guardian or Personal Representative
CDPH 6247 (PDF)Ā - Authorization for Use and Disclosure of Personal Information
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