Patient Request For Privacy Restriction For "Health Care Services Paid For Out-Of-Pocket" Form printable pdf download

PATIENT REQUEST FOR PRIVACY RESTRICTION FOR

“HEALTH CARE SERVICES PAID FOR OUT-OF-POCKET”

Patient Name ____________________________________

Medical Record # _____________________________

Date of Birth

_____________________________________ Phone # (_______)____________________________

Patient Address______________________________ City: ______________________ State: ____ Zip: _________

I understand that I have the right to request that University Health Care not disclose protected health information to my

health plan. University Health Care is not required to agree to the restriction I request unless it is about a health care

service that I have paid for in full and out-of-pocket. In general, payment in full is expected within one billing cycle.

However, University Health Care may require partial or full payment prior to services being rendered.

I understand that if I receive a health care service that I have not paid for in full and out-of-pocket, as agreed, this request

for restriction will no longer be valid. At that time, University Health Care may submit the claim to my health insurance or

initiate other collection activities.

I understand that this restriction applies only to this visit. I understand that if I want the same information restricted from

my health insurance at future visits, I must make a new request.

*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*

Out-of-Pocket Restriction.doc

Rev: 02-01-2010

Patient Request For Privacy Restriction For "Health Care Services Paid For Out-Of-Pocket" Form