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Privacy-HIPAA Forms

CDPH 6234 (Word) - Request for Confidential Communication

CDPH 6235 (Word) - Request for Confidential Communication of Personal Information by Parent, Guardian or Personal Representative

CDPH 6236 (Word) - Request for Access to Personal Information

CDPH 6237 (Word) - Request to Access Personal Information by Parent, Guardian or Personal Representative

CDPH 6238 (Word) - Request to Amend Personal Information

CDPH 6239 (Word) - Request to Amend Personal Information by Parent, Guardian or Personal Representative

CDPH 6240 (Word) - Request to Restrict Use and Disclosure of Personal Information

CDPH 6241 (Word) - Request to Restrict Use and Disclosure of Personal Information by Parent, Guardian or Personal Representative

CDPH 6242 (Word) - Privacy/HIPPA Complaint Form

CDPH 6244 (Word) - Request for an Accounting of Disclosures of Personal Information

CDPH 6245 (Word) - Request for an Accounting of Disclosures of Personal Information by Parent, Guardian or Personal Representative

CDPH 6247 (Word) - Authorization for Use and Disclosure of Personal Information

​​*Documents are currently in the process of conversion to ADA web accessible formats.
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