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DHCS6244 6244 0120

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State of California
Health and Human Services Agency Department of Health Care Services
DHCS 6244 (Rev. 01/20) Page 1 of 2
REQUEST FOR AN ACCOUNTING OF DISCLOSURES OF PROTECTED
HEALTH INFORMATION
File Number: _________________
You have the right to request the Department of Health Care Services to account for the disclosures
of your Medi-Cal information. You are not entitled to an accounting of disclosures to carry out
treatment, payment, or health care operations; when you have authorized the disclosure; or when the
disclosure is to your family, relatives, or others involved in your care. You are also not entitled to an
accounting of disclosures for National Security intelligence purposes or to law enforcement officials.
Mail this completed form, along with a photocopy of your identification and documentation of
your address, to:
Privacy Officer
Department of Healthcare Services
C/O Office of Legal Services
P.O. Box 997413
MS 0010
Sacramento, CA 95899-7413
(916) 445-4646
Individual Information
Last Name:
First Name: Middle Initial:
Address:
City/State: Zip Code:
Benefits ID Number:
Date of Birth:
Telephone Number:
E-mail Address:
I request that the department of health care services account for the disclosure of my
protected health information:
From Date (month/day/year) To Date (month/day/year)
______________________ ____________________
File Number:
From Date (month/date/year) To Date (month/date/year)
State of California
Health and Human Services Agency Department of Health Care Services
DHCS 6244 (Rev. 01/20) Page 2 of 2
Identifying Information:
☐Address verification attached
Type: __________________________ (Utility Bill, Phone Bill, Driver’s License, Etc.)
☐Copy of identification attached
Type: __________________________ (CA Driver’s License, CA DMV Identification Card, Birth
Certificate, Benefits Identification Card, Managed Care Card, State Or Federal Employee ID Card)
Number: ________________________
(IF NO IDENTIFICATION IS ATTACHED, YOUR SIGNATURE MUST BE NOTARIZED)
Notarized By ___________________________________ On ___________________ (Date).
Notary Public Number:________________________________
UNOFFICIAL UNLESS STAMPED BY NOTARY PUBLIC:
I DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION ON THIS FORM IS
TRUE AND CORRECT.
Member Signature:
Date:
NOTE: ANY ATTEMPT TO FALSELY GAIN ACCESS TO PROTECTED HEALTH INFORMATION
IS SUBJECT TO LEGAL PENALTIES.
Address
verification
attached
Type:
Copy
of
identification
attached
Type:
(CA Driver’s License, CA DMV Identification Card, Birth Certificate, Benefits Identification
Card, Managed Care Card, State Or Federal Employee ID Card)
Number:
Notarized By On
Notary Public Number:
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DHCS6244 6244 0120

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Completed 3 July 2020

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