Individual Request Not To Use Or Disclose (Restrict) Health Information Or To End Restriction On Use Or Disclosure Of Health Information Maintained By Arkansas Blue Cross And Blue Shield

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Individual Request Not to Use or Disclose (Restrict) Health Information or to End
Restriction on Use or Disclosure of Health Information Maintained by
Arkansas Blue Cross and Blue Shield
I understand that Arkansas Blue Cross and Blue Shield may use and disclose protected health information about me
for purposes of health care treatment, payment, and health care operations without my consent. I request to restrict
use and disclosure of protected health information concerning health care treatment, payment, or health care
operations about me by Arkansas Blue Cross and Blue Shield in accordance with the Health Insurance Portability
And Accountability Act of 1996 (HIPAA).
Arkansas Blue Cross and Blue Shield Not Required to Agree
I understand that Arkansas Blue Cross and Blue Shield is not required to agree to this restriction.
Termination of Restriction
I understand that if Arkansas Blue Cross and Blue Shield agrees to this restriction, either Arkansas Blue Cross and
Blue Shield or I may terminate this restriction at any time. The termination of the restriction is only effective for
future uses and disclosures.
Emergency Treatment Exception
I understand that if protected health information must be used or disclosed to provide emergency treatment for me,
then this restriction is void.
Questionnaire
Please complete all of the following questions. If the question is not applicable, mark N/A on the answer line.
____ Restriction
____ Discontinue Restriction
(1) I request the following information (description of information)be restricted/ released from restriction:
_________________________________________________________________________________________
_________________________________________________________
(2) I request that use and disclosure of the above described information be restricted in the following manner
(description of restriction):
_________________________________________________________________________________________
_________________________________________________________
(3) I request that my protected health information not be disclosed to the following individuals or entities (List
individuals or entities to which information would not be disclosed):
_________________________________________________________________________________________
_________________________________________________________
I understand that if a restriction is not specifically listed above and agreed to in writing by the group health plan, it
will not be effective.
Termination of Restriction
____ I request that the restriction described above be removed and all information available for treatment, payment,
and health care operations.
Name: _________________________________________________________________________
Address: _______________________________________________________________________
Member Identification Number______________________________________________________
Do you participate in the Federal Employee Program? ____________________________________
Signature:_________________________________________ Date:__________________________
Send completed form to:
Privacy Office
P.O. Box 3216
Little Rock, AR 72203

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