Request Form For Restriction Or Termination Of Restriction On Uses And Disclosure Of Protected Health Information

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Request for Restriction or Termination of Restriction on Uses and Disclosure
Of Protected Health Information (PHI)
Please print all requested information to prevent delays in our response & provide completed form to your facility.
Request Restriction or Termination on Use and Disclosure of
Protected Health Information (PHI)
Patient
Name:___________________________________________________________________________________________________________
Last
First
MI
Maiden or Other Name
Address:____________________________________________________________City:______________________ST: ____Zip:_________
Date of Birth:____-_____-_____
Phone: ___________________________________________________
Please understand that:
 We are not required to agree to this restriction request, unless it is restricting disclosure of your PHI to a health plan or carrier
for treatment or services for which you have paid in full. We may remove the restriction if your payment is not honored.
 We may voluntarily agree to other requests for restrictions. Any restrictions to which we have voluntarily agreed may be
terminated by informing you of the termination.
 This restriction will not apply to any disclosures of PHI which occurred prior to implementation of this request.
 Restrictions will not apply when the restricted information is needed for emergency treatment.
 Restrictions cannot apply to workers’ compensation.
 You may request termination of a previous restriction at any time.
I am requesting that you:  Place a restriction  Remove a previous restriction on the use or disclosure of my protected
health information:
Description of Information to be Restricted:
_____________________________________________________________________________________________________
_
Date of Service: __________________________________
 Individual/Entity to whom PHI should not be disclosed: _____________________________________________________
 Other: ____________________________________________________________________________________________
_______________________________________ ___________ OR ___________________________________________
__________
S
P
D
P
/L
G
/A
P
D
IGNATURE OF
ATIENT
ATE
ARENT
EGAL
UARDIAN
UTHORIZED
ERSON
ATE
_________________________________________________
R
P
ELATIONSHIP TO
ATIENT
FOR INTERNAL USE ONLY
Complete the sections below and place in patient record.
Notice of Decision
We have accepted the restriction(s) you have requested above.
We have accepted only the following portion of the restriction(s) you have requested above:
_________________________________________________________________________________
We are unable to accept the restriction(s) you have requested above.
We are informing you that the above restrictions are being terminated.__________
Date
Termination request on previous restriction has been completed.__________
Date
___________________________________________ _________________________________ _________________ _______________________
Staff Member who processed request
Title
Date
Phone
_________________________________________ _______________________________ ________________ ________________________
Restriction-ENG GCHJF58EN 08.15

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