Privacy-HIPAA Forms

CDPH 6234 (PDF) - Request for Confidential Communication

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

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

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

CDPH 6238 (PDF) - Request to Amend Personal Information

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

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

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

CDPH 6242 (PDF) - Privacy/HIPAA Complaint Form

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

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

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