CDPH 6237: Confidential Request to Access Personal Information by Parent, Guardian, or Personal Representative

Under Individual Whose Information You Are Requesting, enter Last Name, First Name, Middle Initial, Address, City/State, ZIP Code and Date of Birth.

Enter the Date of Death if applicable; the death certificate must be attached.

Under Parent, Guardian, or Personal Representative Information, enter Last Name, First Name, Middle Initial, Address, City/State and ZIP Code.

Enter Daytime Phone Number, Evening Phone Number, Email Address and Best Hours to Reach You.

Under What Legal Authority Do You Have to Request Personal Information About the Individual, mark Parent, Medical Power of Attorney, Guardian, Executor of Will/Trustee, Conservator or Other.

You must attach legal documentation to verify that you are the Parent, Guardian, or Personal Representative of the individual.

Enter the Type of Legal Documentation Attached.

Under Which CDPH Program(s) has/have the personal information about the individual you want to access?, mark AIDS Drug Assistance Program (ADAP), Division of Communicable Disease Control, Newborn Screening Program, Prenatal Screening Program, or Other (Please list CDPH program(s) which may have the personal information).

If the Unknown box is checked, CDPH will contact you to assist in determining which CDPH program(s) may have the personal information for which you are requesting access.

Under I Am Requesting Records for the Following Dates, enter From Date (month/day/year) and To Date (month/day/year); you must specify dates to receive records.

Fulfilling a request for records may take 60-days for processing.

Under Delivery of Records, mark Mail me a copy of the records, Email me a copy of the records, or Fax me a copy of the records, and next to Fax me a copy of the records enter the Fax Number.

Mark I request that a person of my choosing be allowed to receive a copy of the records, then enter Name, Phone Number, Email Address, Address and Relationship to you.

Any person or attorney may be named.

Records will not be sent to photocopy services.

To process your request, you must provide verification of address and identification.

Under Copy of Address Verification Attached, enter the Type (utility bill, phone bill, driver's license, etc.).

Under Copy of Identification Attached, enter the Type (driver's license, DMV ID card, passport, etc.).

If no identification is attached, your signature must be notarized.

Enter Notarized By, Date and Notary Public Number.

Unofficial unless stamped by Notary Public.

Sign on the SIGN line. The form: "I declare under penalty of perjury under the laws of the state of California, that I am the individual noted above, the information on this form is true and correct, and I have a legal right to the information I am requesting."

I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.

Mail, fax, or email the completed form to the Privacy Officer, California Department of Public Health, P.O. Box 997377, MS 0506, Sacramento, CA 95899-7377, Fax: (916) 319-9821, Privacy@cdph.ca.gov.

Any attempt to falsely gain access to personal information is subject to legal penalties.