Healthcare Sealing Instructions

HEALTHCARE SEALING INSTRUCTIONS

Patient Information

Patient Name:

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History (Relevant)

Records to Be Sealed

Select the categories of health information to be sealed. Checking a box instructs the custodian to restrict access to those categories except as provided below.

Medical progress notes    Psychiatric / behavioral health notes    Substance use disorder treatment records

HIV-related records    Laboratory results    Radiology / imaging

Date range for records to be sealed: From to

Restrictions and Authorized Disclosures

Legal Authority, Exceptions, and Limitations

By signing below I direct the custodian of my medical records to apply sealing procedures to the records specified above. I understand that sealed records remain part of my medical record but access will be restricted in accordance with these instructions and applicable law.

I acknowledge that sealed records may nonetheless be disclosed without further authorization in the following circumstances (check all that you understand may apply):

Disclosure pursuant to a valid court order or subpoena    Mandatory reporting of abuse, neglect, or imminent harm    Public health reporting required by law

Law enforcement disclosure permitted by law    Disclosures for payment, treatment, or operations as permitted by law    Other legal exceptions (describe below)

Duration and Revocation

Sealing instructions effective:

Indefinite until revoked    Until date:

Revocation: I may revoke these instructions at any time by providing a signed written revocation to the records custodian. Revocation is effective upon receipt by the custodian except to the extent records were previously disclosed in reliance on these instructions.

Acknowledgment and Certification

I certify that I am the patient or legally authorized representative with authority to direct how these medical records are used and disclosed. I understand that intentionally making false statements in order to obtain sealing of records may expose me to civil or criminal penalties under applicable law.

I understand that the custodian will make reasonable efforts to implement these instructions consistent with applicable legal obligations, but that absolute confidentiality cannot be guaranteed in all circumstances.

HIPAA / Privacy Acknowledgment: I acknowledge that sealing instructions modify certain access procedures but do not alter my other privacy rights. I understand how to request revocation and that this document will be retained in my medical record.

Instructions to Records Custodian

Upon receipt of this signed instruction, the custodian shall:

1. Identify and flag the specified records to restrict routine access consistent with these instructions.
2. Document the request and any disclosures made pursuant to legal exception or court order in the record audit log.
3. Provide notice to treating providers as necessary for ongoing treatment while limiting broader access as directed.

Patient Signature

Sign Now