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CONSUMER REQUEST FOR CHANGE OF PROVIDER FORMCONTRA COSTA COUNTY BEHAVIORAL HEALTH SERVICESMHA54 (rev.1218)LANGUAGE ASSISTANCE English ATTENTION: If you speak another language, language assistance

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How to fill out timely access notice

01

Step 1: Begin by obtaining a timely access notice form from your healthcare provider.

02

Step 2: Fill out the personal information section, including your full name, contact details, and date of birth.

03

Step 3: Specify the type of health information you are requesting access to.

04

Step 4: Indicate the desired timeframe for receiving the requested information.

05

Step 5: Sign and date the form.

06

Step 6: Submit the completed form to your healthcare provider through their designated channels (such as in-person, mail, or online).

07

Step 7: Keep a copy of the filled-out form for your records.

08

Step 8: Await a response from your healthcare provider regarding the availability of the requested information within the specified timeframe.

Who needs timely access notice?

01

Anyone who wishes to obtain timely access to their own health information from a healthcare provider needs a timely access notice. This includes patients, individuals acting on behalf of patients (such as legal guardians or authorized representatives), or anyone who legally has the right to access the health information of another individual (such as a parent requesting information about their child's health).

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What is timely access notice?

Timely access notice is a document that informs the relevant parties about the timely access to certain information or resources.

Who is required to file timely access notice?

The parties responsible for providing access to the information or resources are required to file timely access notice.

How to fill out timely access notice?

Timely access notice can be filled out by providing the necessary information and submitting it to the designated parties within the specified deadline.

What is the purpose of timely access notice?

The purpose of timely access notice is to ensure that relevant parties are informed about the availability of certain information or resources within the specified timeframe.

What information must be reported on timely access notice?

The information that must be reported on timely access notice includes details about the resources or information being made available, the timeframe for access, and contact information for inquiries.

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