Form Hfs 3806H PDF Details

In the bustling state of Illinois, individuals who receive health benefits or services from the Department of Healthcare and Family Services possess a valuable right—the ability to request amendments to their personal health information. This privilege is encapsulated within the HFS 3806H form, a critical document designed to empower users by allowing them to seek changes to their health records held by the agency. While the form opens the door for modifications, it's important to note that the agency holds the discretion to deny a request if the information in question is already accurate, wasn't produced by the department, falls outside of the designated record set, or is inaccessible to the patient. Additionally, the department commits to providing a response within a reasonable timeframe, typically within 60 days, to inform the individual of whether their request can be accommodated or if further time is required to make a decision. Complete with fields for personal details, the specific amendments desired, and the reasons behind them, the form also outlines channels for inquiries, emphasizing the availability of a Privacy Officer to assist through phone or email. The process, while straightforward, underscores the importance of clear communication and provides a tangible avenue for individuals to have a say in the management of their personal health information.

QuestionAnswer
Form NameForm Hfs 3806H
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameshfs3806h hfs illinois change of address form

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State of Illinois

Department of Healthcare and Family Services

REQUEST TO AMEND HEALTH INFORMATION

You have the right to ask the Illinois Department of Healthcare and Family Services (Agency) to amend your personal health information that it has.

The Agency does not have to agree to your request if the personal health information it has about you is accurate and complete, or was not created by the Agency, or is not part of a designated record set, or is not available for you to see.

The Agency is required to tell you within 60 days after it receives your request if it will agree to your request or if it needs more time to respond to your request.

My name:

 

Date of birth:

I request that the Agency amend my personal health information in this way:

This is the reason why I am asking the Agency to amend my personal health information

Signature:Date:

Send this Personal Representative

If you have any questions, contact the Privacy

Designation or Revocation to:

Office at the address to the left, or the phone

 

number below. The call is free.

Privacy Officer

 

Healthcare and Family Services

Toll-free telephone: 1-800-226-0768

P.O. Box 19159

(Health Benefits Hotline)

Springfield, Illinois 62794-9159

Toll-free for persons using a TTY:

 

1-877-204-1012

Fax: 1-217-524-2397

 

 

e-mail address: privacy.officer@illinois.gov

HFS 3806H (R-6-09)

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