Fill and Sign the Restrictions Form

REQUEST FOR RESTRICTIONS ON USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION I hereby request that _____________ restrict use and disclosure of my health information as described below. D ATE :       PATIENT/RESIDENT/CLIENT L AST N AME :       F IRST N AME :       M IDDLE I NITIAL :       A DDRESS       C ITY /S TATE :       Z IP C ODE :       T ELEPHONE N UMBER :       SSN (O PTIONAL ):       D ATE OF B IRTH :       AKA’ S :       I AM REQUESTING THE FOLLOWING RESTRICTIONS ON THE USE AND DISCLOSURE OF INFORMATION CONTAINED IN MY MEDICAL OR BILLING RECORDS: PATIENT RIGHTS I understand I have the right to request a restriction on how my health information is used or disclosed. I may request restriction of uses and disclosures of my protected health information to carry out treatment, payment, and health care operations, disclosures to a family member, other relative, close personal friend, or any other person involved in my care, and disclosures of protected health information to notify, or assist in the notification of a family member, a personal representative, or another person responsible for my care, of my location, general condition, or health. I understand that my request must be submitted in writing. _____________ RESPONSIBILITIES _____________ is not required to grant any restrictions and cannot grant any restrictions that would violate the law . A decision regarding the request will be rendered within a reasonable time period. If the request is granted, _____________ must abide by the restrictions unless I agree to terminate the restriction or _____________ tells me it is terminating the original agreement. I understand _____________ may disregard the restriction agreement without my approval if I am in need of emergency treatment and the restricted information is needed to provide the emergency treatment. QUESTIONS If you have any questions regarding restrictions of your health information, please contact: Privacy Officer ______________________________ ______________________________ ______________________________ ______________________________ SIGNATURE OF INDIVIDUAL OR LEGAL REPRESENTATIVE S IGNATURE :       D ATE :       I F S IGNED BY L EGAL R EPRESENTATIVE , R ELATIONSHIP TO I NDIVIDUAL :       THIS SECTION IS FOR _____________ USE ONLY The above request for restriction of health information by the above named individual has been: Granted __________ Denied___________ Reason(s) for Denial, if Applicable ____________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________ ___________________ _____________ Privacy Officer Date