Hipaa - Form A - Request For Limitations And Restrictions Of Protected Health Information Page 2

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HIPAA – FORM A
PEDIATRIC ASSOCIATES
FUNDRAISING ACTIVITIES – RIGHT TO OPT OUT
III.
I, _______________________ am requesting that Pediatric Associates or its related entities do not communicate with me or any of
my representatives regarding fundraising activities by telephone, regular mail or electronic mail and will not use my name, address,
telephone number and dates of service that I received care to gather information for fundraising purposes in accordance with the
HIPAA Privacy, Security, Enforcement and Breach Notification Rules Under the Health Information Technology for Economic and
Clinical Act (HITECH) and the Genetic Information Nondiscrimination Act published January 25, 2013.
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
IV.
RESTRICT DISCLOSURE TO HEALTH PLANS FOR TREATMENT PAID OUT OF POCKET IN FULL
I, _______________________ am requesting that Pediatric Associates not disclose any information to my health insurance carrier for
date of service _______________ for treatment received in accordance with the HIPAA Privacy, Security, Enforcement and Breach
Notification Rules Under the Health Information Technology for Economic and Clinical Act (HITECH) and the Genetic Information
Nondiscrimination Act published January 25, 2013. I do not authorize Pediatric Associates to request payment for this visit from my
health insurance provider. I understand that I am financially responsible for all charges related to this visit.
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
V.
RESTRICT DISCLOSURE OF IMMUNIZATION RECORDS TO SCHOOLS
I, _______________________ am requesting that Pediatric Associates not disclose any of my immunization records to any school in
accordance with the HIPAA Privacy, Security, Enforcement and Breach Notification Rules under the Health Information Technology
for Economic and Clinical Act (HITECH) and the Genetic Information Nondiscrimination Act published January 25, 2013.
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
VI.
RESTRICT DISCLOSURE OF PROTECTED HEALTH INFORMATION IN THE EVENT OF DEATH
I, _______________________ am requesting that Pediatric Associates not disclose any decedent information to family members or
others in the event of my death in accordance with the HIPAA Privacy, Security, Enforcement and Breach Notification Rules Under
the Health Information Technology for Economic and Clinical Act (HITECH) and the Genetic Information Nondiscrimination Act
published January 25, 2013.
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
FOR INTERNAL PURPOSES ONLY
Name & Title of Staff Receiving Form __________________________________________
:
Date Staff Received Form:______________________ Date Compliance Officer Received Form: _______________________________
Approval Status:
Approved as requested
Denied & Notified Date: ________________ Method: _______________________
Approved with modification: ____________________ Compliance Officer Initials: _______ Priv. Admin. Initials: ______________
1/03, Rev 4/03, 01/05, 2/05, MC04/10, 12/13, 05/14
Page 2

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