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Request For A Restriction On Protected Health Information Form - Privacy Officer Agency For Health Care Administration

Request for a Restriction on Protected Health Information

Federal law says that you have the right to request a restriction on certain uses and

disclosures of your protected health information. See the other side for information

about your right to request a restriction and the uses and disclosures on which you

may request a restriction. The agency is not required to agree to a restriction.

Name___________________________________________ Date of Birth ________________________

Phone Number (___)______________ Social Security Number _______________________________

Street Address _______________________________________________________________________

City ________________________________ State __________________ Zip ___________________

If you receive Medicaid, enter your Medicaid ID number or gold card number from the back of your

Medicaid ID card _____________________________________________________________________

I am asking to restrict the following health information from being used and disclosed. (Please be

specific about the information and state whom you do not want to have the information. For example,

Do not disclose any information about my claims to my husband.)

____________________________________________________________________________________

Signature ___________________________________________________ Date___________________

Signature of Authorized Representative ___________________________ Date __________________

Relationship of Authorized Representative _________________________________________________

(Attach documentation that you are a personal representative, for example: authorization form, durable

power of attorney, court order, guardianship papers)

To Be Completed by the Agency for Health Care Administration

Approved ___________________________________________________________________________

Denied _____________________________________________________________________________

(Give the reason)

Comment ___________________________________________________________________________

________________________________________________ ___________________________________

AHCA Representative Signature

Date

Version 5

AHCA

Request For A Restriction On Protected Health Information Form - Privacy Officer Agency For Health Care Administration