Mr-4641 - Request For Restriction On Use & Disclosure Of Health Information Form

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Oregon Health & Science University
Hospitals and Clinics
Integrity Office
ACCOUNT NO.
3181 SW Sam Jackson Park Rd
Mail Code: L106-IO
MED. REC. NO.
Portland, OR 97239-3098
(503) 494-0219, Fax (503) 494-4828
NAME
BIRTHDATE
Page 1 of 1
Patient Identification
REQUEST FOR RESTRICTION ON USE & DISCLOSURE OF HEALTH INFORMATION
SECTION A: Individual to complete the following information. (Please print)
NAME ____________________________________________________________________________________
Last
First
Middle
ADDRESS _________________________________________________________________________________
TELEPHONE NO. ___________________________
BIRTH DATE __________________________________
MEDICAL RECORD NO. _____________________
(If applicable)
REQUEST:
I hereby request that Oregon Health & Science University (OHSU) restrict the use & disclosure of health information
in the following manner:
Please specify the type of health information and the requested restriction:
__________________________________________________________________________________________
__________________________________________________________________________________________
Please indicate the specific OHSU service area or department for which this applies: ______________________
ACKNOWLEDGEMENT OF CONDITIONS OF RESTRICTION
I understand that OHSU does not have to agree to my requested restriction(s). If OHSU agrees to the requested
restriction, then the restriction is in effect (unless emergency circumstances require otherwise) until one of the
following events occurs:
•
I agree to or request that the restriction be terminated; or
•
OHSU notifies me in writing that they are terminating restriction in which case the termination is effective
only as to information created or maintained after I am notified of the termination.
Documentation about an acceptance or denial of a request is maintained at the OHSU Integrity Office and can be
obtained by calling (503) 494-0219.
Date: _________________
Signature of Patient or Legal Representative ____________________________________________________
Printed Name of Legal Representative (If applicable) ______________________________________________
SECTION B: All requests shall be forwarded to the OHSU Privacy Officer or designee for review.
Request for restriction is:
Accepted
Denied
MR1449
Staff comments _____________________________________________________________________________
__________________________________________________________________________________________
Signature of staff person ____________________________________ Date _____________ Time:
Print name and title _________________________________________________________________________
Department / Area ___________________________________________________________________________
MR-4641
ONLINE 3/13 (Supersedes 6/11)

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