Fillable INDIVIDUAL REQUEST FOR ACCESS TO PROTECTED HEALTH INFORMATION (CalOptima)

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INDIVIDUAL REQUEST FOR ACCESS TO PROTECTED HEALTH INFORMATION (CalOptima)

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MCAL MM-18-142_DHCS Approved 10.18.18_Individual Request for Access to PHI Contained in DRS
Page 1 of 3
Rev. 09/18
INDIVIDUAL REQUEST FOR ACCESS TO PROTECTED HEALTH INFORMATION (PHI)
CONTAINED IN THE DESIGNATED RECORD SET (DRS)
You have the right to inspect your protected health information (PHI) in the Designated Record Set (DRS). You
also have the right to request copies of those records. You will receive a response to your request within 30 days
after we receive the completed form. If the information is not readily available, CalOptima has up to 60 days to
provide you with your PHI. CalOptima may charge a fee of $0.10 per page and any postage fees if you ask for
copies of the records to be mailed to you.
To Request a Copy of Your PHI in a DRS:
1. Fill out the entire form and print clearly. In order to process your request, a photocopy of your valid
photo identification (ID) must be included with your request form.
2. If you would like to appoint another person to have access to or receive your PHI, then you must also
complete the CalOptima Authorization for Release of Protected Health Information form. Requests by
your personal representative are subject to verification.
3. Please select the type of records you need from the list provided. If you are not sure what you need, please
call CalOptima Customer Service toll-free at 1-888-587-8088 for help. .
4. If you were a part of a health network (e.g. Monarch, AltaMed, etc.) during any part of the date range
requested, you should also contact that health network. CalOptima does not have complete copies of
your medical records. If you want to look at or get a copy of your medical records, please contact
your doctor or clinic.
5. If you have any questions about your request, please call CalOptima Customer Service toll-free at
1-888-587-8088, Monday through Friday from 8 a.m. to 5:30 p.m. TDD/TTY users can call toll-free at
1-800-735-2929. We have staff who speak your language.
6. Your records may be picked up at CalOptima’s office or sent via email or certified postal mail. Requests
for records to be faxed must be approved by CalOptima. Records sent via email will be sent secure
(encrypted) to the email address provided. However, CalOptima is not responsible for loss of PHI on
personal email accounts.
MCAL MM-18-142_DHCS Approved 10.18.18_Individual Request for Access to PHI Contained in DRS
Page 2 of 3
Rev. 09/18
INDIVIDUAL REQUEST FOR ACCESS TO PROTECTED HEALTH INFORMATION (PHI)
CONTAINED IN THE DESIGNATED RECORD SET (DRS)
Member Name: Date of Birth:
(mm/dd/yyyy)
Phone: CalOptima CIN:
The types of records listed below are part of the DRS maintained by CalOptima. Please select the types
of records you wish to view or receive as well as the date range.
Authorizations
☐ Medical Authorization Request(s)
☐ Pharmacy Prior Authorization(s) (PA)
☐ Notice of Action(s)
Behavioral Health Record(s)
☐ Behavioral Health Authorization(s)/Denials
☐ Care Management Notes
Case Management
☐ Case Management Note(s)
☐ Case Management Care Plan(s)
☐ Case Management Assessment(s)
Claims/Billing
☐ Medical Claims Record(s)
☐ Pharmacy Claims Record(s)
Customer Service
☐ Member Call Logs
Eligibility
☐ Eligibility Record(s)
☐ Auto Assignment and Health Network
Changes
☐ Enrollment Form(s) (Does not apply to Medi-
Cal Members)
Grievances and Appeals (GARS)
☐ Grievance Case File Record(s)
☐ Appeal Case File Record(s)
Health Education and Disease Management
☐ Care Plan(s)
☐ Assessment(s)
☐ Health Ed. and Disease Mgmt. Notes
Long-Term Services and Supports (LTSS)
☐ Assessment(s)
☐ Authorization(s)
☐ Case Management Notes
Multipurpose Senior Services Program (MSSP)
☐ Assessment(s)
☐ Care Plan(s)
☐ Referral Form(s)
☐ Progress Notes
☐ Application Form
State Hearing(s)
☐ State Hearing Record(s)
I am requesting copies of records for the following dates of service: to
(mm/dd/yyyy) (mm/dd/yyyy)
Requests submitted without a date range will be considered incomplete.
Delivery method requested (select one):
☐ “Personal” pickup at CalOptima (identification required at the time of pickup)
☐ Mail:
Street/Unit City State ZIP Code
MCAL MM-18-142_DHCS Approved 10.18.18_Individual Request for Access to PHI Contained in DRS
Page 3 of 3
Rev. 09/18
☐ Fax (Upon approval): ☐ Email: ___________________________________
Identifying information is required (select one):
☐ Copy of ID attached (e.g. valid driver license, birth certificate, benefits ID card, etc.)
☐ If no ID is attached, your signature must be notarized.
Notarized By:
Notary Public Number:
Date:
Signature Block:
(I understand that to process my request, a copy of valid, government-issued identification (ID), a copy
of documentation of legal authority, or a notarized signature must be included with my request form.)
By signing below, I state that I have read this form and know what it means.
Signature of Member/Personal Representative
Date
Parent/Guardian Signature: Date:
Parent/Guardian Printed Name: Relationship:
CalOptima reserves the right to request legal documentation (e.g., birth certificate, court order, etc.) from the
parent/guardian signing on behalf of a dependent member.
Personal Representatives — Please attach legal documentation to verify that you are the conservator,
executor of a decedent’s will, or have medical decision-making authority for the individual.
Submit the completed and signed request form and copy of ID to CalOptima, either in person, by mail or by fax.
CalOptima
Attn: Office of Compliance (Privacy)
505 City Parkway West, Orange, CA 92868
Fax: 1-714-481-6457
Unofficial Unless Stamped by Notary Public
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INDIVIDUAL REQUEST FOR ACCESS TO PROTECTED HEALTH INFORMATION (CalOptima)

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Completed 11 March 2021

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