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Request For A Restriction On Protected Health Information Form - Privacy Officer Agency For Health Care Administration Page 2

Your Right to Restrict Your Protected Health Information

You have a right to request a restriction on certain uses and disclosures of the protected health

information about you that is in the Agency for Health Care Administration records. You may

request restrictions on uses and disclosures for treatment, payment, and health care

operations; information to individuals involved in your care; and information for disaster relief

purposes. You may submit your request directly to the Privacy Officer at the address given at

the bottom of this page or to your Area Office, which will forward it to the Privacy Officer.

You may request a restriction only on uses and disclosures:

• To carry out treatment, payment, or health care operations;

• To individuals (family member, relative, friend, etc.) who are involved in your care or

payment for your care; or

• For disaster relief purposes.

The Agency is not required to agree to a restriction.

If you are in need of emergency treatment, and the restricted information is needed to provide

the emergency treatment, the Agency may disclose this information.

The Agency may terminate its agreement to a restriction if:

• You request the termination; or

• The Agenc y informs you that it is terminating its agreement to the restriction. A termination

will only apply to protected health information that the Agency creates or receives after it

informed you about the termination of the restriction.

If you have any questions about restricting your protected health information, call or write to:

Privacy Officer

Agency for Health Care Administration

2727 Mahan Drive, Mail Stop 4

Tallahassee, Florida 32308

Phone: 850-4

Version 5

AHCA

Request For A Restriction On Protected Health Information Form - Privacy Officer Agency For Health Care Administration Page 2