This notice is provided pursuant to the Information Practices Act of 1977 and applies when the California Department of Human Resources (CalHR) uses this form to collect personal information from individuals. Other agencies and departments that use this form to collect personal information from individuals may provide a separate privacy notice pursuant to California Civil Code section 1798.17 of the Information Practices Act of 1977.
The California Department of Human Resources (CalHR), Benefits Division, is requesting the information specified on this form pursuant to Government Code Sections 1151, 1153, Section 6011 and 6051 of the Internal Revenue Code, and Regulation 4, Section 404.1256, Code of Federal Regulations, under Section 218, Title II of the Social Security Act.
The information collected will be used for the State Dental Program and will be disclosed to the State Controller and/or the California Public Employees' Retirement System, and the dental plan.
Individuals should not provide personal information that is not requested or required.
The submission of all information requested is mandatory unless otherwise noted. If you failed to provide the information requested, CalHR or the requesting department, and the dental plan will not be able to process your request for dental plan enrollment.
The information collected by CalHR is subject to the limitations in the Information Practices Act of 1977 and state policy. For more information on how we care for your personal information, please read our Privacy Policy.
Access to Your Information
The CalHR Privacy Officer is responsible for maintaining collected records. You have a right to access records containing your personal information we maintain. To request access, contact:
CalHR Privacy Officer
1515 S Street, Suite 500
Sacramento, CA 95811
Kant.Deemark@calhr.ca.gov
916-562-8057
NOTE: All requests should be referred to the requesting department if different from CalHR.
Revision Date: 5/2023
