Hipaa - Form A - Request For Limitations And Restrictions Of Protected Health Information

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HIPAA – FORM A
PEDIATRIC ASSOCIATES
R
F
L
R
EQUEST
OR
IMITATIONS AND
ESTRICTIONS OF
P
H
I
ROTECTED
EALTH
NFORMATION
PLEASE NOTE:
U
R
. P
N
NDER GOVERNMENT
EGULATION WE ARE NOT REQUIRED TO AGREE TO YOUR REQUEST
LEASE SEE OUR
OTICE OF
P
P
. I
RIVACY
RACTICES FOR MORE INFORMATION REGARDING SUCH REQUESTS
F WE ARE UNABLE TO APPROVE YOUR
,
R
30
.
REQUEST
WE
ESERVE THE RIGHT TO REPLY WITHIN
DAYS
Patient Name: _______________________________________ Date of Birth: _____________________ Chart / Account #: ______________
Patient Address: _____________________________________ City, State, Zip: ___________________________ Phone: ___________________
Street
I.
CHART RESTRICTIONS (to identify a person/people we should not communicate with)
Type of Protected Health Information (PHI) to be restricted: (Please check all that apply)
Home phone #/Home address
Spouse office phone #
Hospital notes
Office phone #/ Office address
Other
Prescription Information
Occupation/Name of employer
Patient history
All Information *(see below)
Spouse name
Visit notes
How would you like your Protected Health Information (PHI) restricted?
____________________________________________________________________________________________________
____________________________________________________________________________________________________
* IMPORTANT: Information will only be restricted from parties not involved in the provision of, payment for, or healthcare
operations of your child’s care. It will be necessary for us to continue to release information to your insurance company and/or other
healthcare providers. If you have any concerns about this, please call our Compliance Officer directly at 954-965-7353.
____________________________________
_____________________________
________________________
Signature of Patient or Legal Guardian
Printed Name of Parent/Guardian
Date
II.
CONFIDENTIAL COMMUNICATIONS (to identify a need for us to communicate with you in a special way).
THIS REQUEST CANNOT BE EXECUTED UNLESS COMPLETED
I, ___________________, am requesting that Pediatric Associates communicate with me in the alternative manner and/or location
described below regarding my/my child’s/children’s health information (information that constitutes protected health information as
defined in the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act
of 1996). Such restriction is necessary to prevent a disclosure that could endanger me. I understand that Organization may deny this
request if it imposes an unreasonable administrative burden.
Description of the Health Information that Must be Communicated Confidentially. The following is a description of the specific health
information to which this request applies:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Alternative Manner and/or Location. In order to communicate with you about this visit, we must have a phone number where you can
be reached. I request that Pediatric Associates to only communicate with me in the following manner and/or at the location described
below. I agree that I can be reached at the following PHONE NUMBER if any communication regarding this visit is required:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
By signing this form, I am confirming that it accurately reflects my wishes
____________________________________
_____________________________
________________________
Signature of Patient or Legal Guardian
Printed Name of Parent/Guardian
Date
1

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