Fillable Patient Request For Special Privacy Restriction Form printable pdf download

Patient Request For Special Privacy Restriction Form

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PATIENT REQUEST FOR SPECIAL PRIVACY RESTRICTION

Patient Name ____________________________________

Medical Record # _____________________________

Date of Birth

_____________________________________ Phone # (_______)____________________________

Patient Address______________________________ City: ______________________ State: ____ Zip: _________

Soc. Sec.#

____________________________________ (Providing your SS# is voluntary, but necessary to

accurately identify your medical records, if you fail to provide Medical Record Number

Approximate Dates of Treatment: ___________________________________________________________________

I request that the University of Utah Health Care (“UHC”) restrict the use or disclosure of my protected health information

for treatment, payment, or health care operations in the manner described here (please be specific):

____________________________________________________________________________________

I understand that the UHC is not required by law to accept my requested restrictions, but if accepted, the UHC agrees to

abide by the restrictions except in emergency situations. I understand that if this request is accepted and put into

place, it may impact my care and/or safety negatively. I also understand that either I or the UHC may terminate this

restriction in writing at any time in the future.

*Description of Personal Representative Authority:

_______________________________ ___________

Signature of Patient or Representative Date

Parent

Medical Power of Attorney

____________________________________________

Other, explain: _____________________

If Applicable, Print Name of Personal Representative*

and attach documentation.

Signature must be verified by UHC staff or must be notarized. When complete, place in patient’s medical record.



_____________________________

______________________________

_________

Signature of UHC Employee

Printed Name and Employee ID#

Date



SUBSCRIBED AND SWORN before me this ____ day of ________________, 20____.

NOTARY PUBLIC

Residing in ________________________________

My Commission expires: _____________________

*RELEASE OF INFORMATION*

Final Patient Request for Special Privacy Restrictions 1-15-2008.doc

Rev: 11-09-2009

Patient Request For Special Privacy Restriction Form

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