Dhcs 6247 Form PDF Details

Dhcs 6247 form is a California Department of Health Care Services form used to apply for Medi-Cal benefits. This form can be used by individuals, families, or groups. The Medi-Cal program provides health coverage for low-income individuals and families in the state of California. In order to qualify for Medi-Cal benefits, applicants must meet certain eligibility requirements. The Dhcs 6247 form can be downloaded from the Department of Health Care Services website or obtained from local social service agencies. Completed applications can be submitted by mail or in person at a local DHCS office.

QuestionAnswer
Form NameDhcs 6247 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names6247, protected, authorization, dhcs form 6247

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STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY

DEPARTMENT OF HEALTH CARE SERVICES

 

 

 

PRIVACY OFFICE

 

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

 

 

 

 

 

 

I,

 

, hereby authorize

 

to

 

(Name of patient)

(Name of person or facility which has information)

release the following health information:

To:

(Name and title or facility name to receive health information)

(Street address, city, state, ZIP code)

(Telephone number)

(Fax number)

For the following purposes:

This authorization is in effect until

 

(date or event), when it expires.

I understand that by signing this authorization:

•I authorize the use or disclosure of my individually identifiable health information as described above for the purpose listed.

•I have the right to withdraw permission for the release of my information. If I sign this authorization to use or disclose information, I can revoke that authorization at any time. The revocation must be made in writing and will not affect information that has already been used or disclosed.

•I have the right to receive a copy of this authorization.

•I am signing this authorization voluntarily and treatment, payment, or my eligibility for benefits will not be affected if I do not sign this authorization.

•I further understand that a person to whom records and information are disclosed pursuant to this authorization may not further use or disclose the medical information unless another authorization is obtained from me or unless such disclosure is specifically required or permitted by law.

Signed by Patient:

Date

 

 

Or Signed by Personal Representative:

Date

_____________________________________________________

 

On Behalf of

 

_____________________________________________________

 

Name of Patient

 

DHCS 6247 (11/07)

Page 1 of 2

IDENTIFYING INFORMATION

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

NOT OFFICIAL UNLESS STAMPED BY NOTARY PUBLIC

PERSONAL REPRESENTATIVE INFORMATION

WHAT LEGAL AUTHORITY DO YOU HAVE TO MAKE MEDICAL DECISIONS FOR THE

PATIENT?

PARENT

GUARDIAN

MEDICAL POWER OF ATTORNEY

CONSERVATOR

EXECUTOR OF WILL

OTHER

NOTE: ATTACHING LEGAL DOCUMENTATION IS REQUIRED TO VERIFY THAT YOU ARE THE PARENT, CONSERVATOR, GUARDIAN, EXECUTOR OF A DECEDENT’S WILL, OR HAVE MEDICAL DECISION-MAKING AUTHORITY FOR THE INDIVIDUAL.

DHCS 6247 (11/07)

Page 2 of 2

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To be able to complete this document, be sure you type in the right information in each and every blank:

1. You should fill out the dhcs 6247 properly, thus take care when working with the sections including all of these blanks:

The best way to fill out dhcs 6247 authorization part 1

2. The subsequent part is to fill out these blank fields: For the following purposes, This authorization is in effect, date or event when it expires, I understand that by signing this, I authorize the use or disclosure, I further understand that a, Signed by Patient, and Date.

dhcs 6247 authorization completion process detailed (stage 2)

3. This next segment will be about Or Signed by Personal, Date, DHCS, and Page of - type in each of these blanks.

DHCS, Page of, and Or Signed by Personal of dhcs 6247 authorization

4. The fourth subsection comes with the next few blank fields to focus on: COPY OF IDENTIFICATION ATTACHED, TYPE IDENTIFICATION CARD BIRTH, CA DRIVERS LICENSE CA DMV, NUMBER, IF NO IDENTIFICATION IS ATTACHED, NOTARIZED, NOTARIZED BY, DATE, and NOTARY PUBLIC NUMBER.

Find out how to prepare dhcs 6247 authorization portion 4

Be extremely mindful while completing TYPE IDENTIFICATION CARD BIRTH and NUMBER, as this is where many people make mistakes.

5. The pdf should be concluded by going through this area. Here there can be found a comprehensive list of form fields that need accurate details for your form usage to be faultless: PARENT, GUARDIAN, CONSERVATOR, EXECUTOR OF WILL, MEDICAL POWER OF ATTORNEY, OTHER, NOTE ATTACHING LEGAL DOCUMENTATION, DHCS, and Page of.

PARENT, Page of, and MEDICAL POWER OF ATTORNEY inside dhcs 6247 authorization

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