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PRIVACY STATEMENT |
RIGHTS AND RESPONSIBILITIES |
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This renewal form is for renewing benefits through the department |
the information I gave on this renewal form is true as far as I know. |
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of Health Care services (dHCs) and determining eligibility for |
I know that I may be subject to a penalty if I do not tell the truth. |
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health insurance through Covered California. the personal and |
I understand that the information I give will be used only to see |
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medical information you provide on it is private and confidential. |
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if those in my family who are applying to renew hea th insurance |
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Covered California or DHCs needs it to identify you and the other |
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will qualify. |
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people on this renewal form and to administer our programs. We |
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will share your |
information with other state, federal, and local |
I understand that Covered California and the Medi-Cal program |
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agencies, contractors, health plans, and programs only to enroll |
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will keep my information private, as the law requires. For more |
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you in a plan or program or to administer programs, and with other |
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information, or access |
to personal information in records |
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state and federal agencies as required by law. |
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Purposes |
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maintained by the Medi-Cal program and Covered California, |
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You must answer all of the questions on this renewal form unless |
I can contact my county social ervices office or I can contact |
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the Covered California |
Privacy Officer at 1-800-300-1506 |
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they are marked “optional.” If your renewal form is missing anything |
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(TTY: 1-888-889-4500). |
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that we require, we will contact you to get it. If you do not provide it, |
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we will not be able to make a decision on your renewal. You may |
I understand that to be eligible for Medi-Cal, I am required to |
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have to submit a new application, or you may not be able to get |
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apply for other inc me |
benefits to which I or any member of |
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health insurance through Covered California, or your application |
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my household is entitled, unless he or she has good cause for |
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for benefits renewal may be denied. |
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not doing so. exam les of such income or benefits are pensions, |
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In most cases, you have the right to see personal information |
government benefits, retirement income, veteran’s benefits, |
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about you that is in federal and state records. You can see it in |
ann ities, disability benefits, social security benefits (also |
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an alternative format (such as large print) if you need that. For |
called OAsdI or Old Age, survivors, and disability Insurance), |
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more information or to see Covered California records, contact the |
and unemployment benefits. But such income or benefits do |
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Privacy Officer at: |
not include public assistance benefits, such as CalWOrKs or |
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Informational |
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Covered California |
Ca Fresh. If I have a question about a possible source of income, |
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I can call my county social services office or Covered California at |
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Attn: Privacy Officer |
1-800-300-1506 (TTY: 1-888-889-4500) for help. |
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P.O. Box 989725 |
I know that I must tell Covered California or my Medi-Cal county |
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West sacramento, CA 95798-9725 |
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Phone: 1-800-300-1506 |
social services office about changes to anything I stated in this |
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TTY: 1-888-889-4500 |
renewal form. to report changes, I can call my county social |
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For the Department of Health Care Services, |
services office. Or I can call Covered California at 1-800-300-1506 |
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(TTY: 1-888-889-4500) or visit CoveredCA.com. |
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contact the Information Protection unit t: |
I know that Covered California or the Medi-Cal program must |
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P.O. Box 997413, Ms 4721 |
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sacramento, Ca |
not discriminate against me or anyone on this renewal form |
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95899-7413 |
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because of race, color, national origin, religion, age, sex, sexual |
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Phone: 1-866-866-0602 |
orientation, marital status, veteran’s status, or disability. If I think |
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TTY: 1-877-735-2929 |
Covered California or the Medi-Cal program has discriminated |
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these state and federal laws give us the right to collect and keep |
against me, including the failure to provide reasonable accom- |
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modations as required under state and federal law, I can make a |
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the information |
the re ewal form: Covered Ca: 42 u.s.C. § |
complaint by contacting the u.s. Department of Health & Human |
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18031; CA Gove nment Code §§ 100502(k) and 100503(a) dHCs: |
services at www.hhs.gov/ocr/office/file or the California |
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CA Welfa e and Institutions Code § 14011 and Article 3, Chapters |
Office of the Attorney General at http://oag.ca.gov/contact/ |
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5 and 7, Parts 2 and 3, division 9. We must give you this Privacy |
general-comment-question-or-complaint-form. |
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statement under CA Civil Code § 1798.17. |
If I believe that Covered California or the Medi-Cal program has |
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You can find the Notices of Privacy Practices for the Medi-Cal |
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discriminated against me or anyone else on this renewal form in |
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program at www.dhcs.ca.gov and for Covered California at |
connection with a Medi-Cal eligibility determination, I can also file |
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www.CoveredCA.com. |
a complaint with the department of Health Care services, Office |
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of Civil rights by calling 1-916-440-7370 (TTY: 1-916-440-7399). |