Restriction Request Form For Use And Disclosure Of Protected Information
ADVERTISEMENT
1
2Pt. Name:______________________________________________
Address:_______________________________________________
______________________________________________________
City
State
Zip
MRN: _________________________________________________
DOB: _________________________________________________
Restriction Request Form
SEX:______
For Use and Disclosure of Protected
DOS: _________________________________________________
Health Information
Date:
You are requesting that UT Southwestern Medical Center restrict its use and disclosure certain types of your protected health
information as described below. Please be aware that UT Southwestern Medical Center is not required to grant your
request. For example, UT Southwestern Medical Center may refuse any request for a restriction that could interfere with
your care. If we grant your request, we will honor the restriction, except in instances in which the information is necessary for
emergency care. You will be notified in writing of UT Southwestern Medical Center’s decision to grant or deny your request. Until
a decision is reached, your request for restriction will not be honored. UT Southwestern Medical Center will respond to your
request within 30 business days from the date of receipt of your request. Complete and return this form by mail to:
Privacy Officer
UT Southwestern Medical Center
5323 Harry Hines Boulevard
Dallas, Texas 75390-8851
Please describe the information you wish to restrict. Please provide specific details and dates if applicable.
Please describe the reason for your request. Was this visit self-paid in full?
n
No
n
Yes
Please list the specific names, addresses and phone numbers of the persons or businesses whom you wish not to receive your
health information.
If we have questions in the process of evaluating your request, how may we contact you?
Patient Signature
Time
Date
Print Patient Name
Legal Guardian or Patient Representative Signature
Time
Date
Print Legal Guardian or Patient Representative Name
Relationship to Patient
Office Use Only
n
Request Received:
Time:
Date:
n
n
n
Request Granted
Request Denied
Patient Notification Mailed
Date:
Authorization Signature:
Date:
Copy to be retained by Privacy Office
n
Original to HIM:
Date:
Page 1 of 1 (See other side for instructions)
Form # FMA/RRFDPHI-001 / 02.03
(Rev. 07.12)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Request Form For Restriction Or Termination Of Restriction On Uses And Disclosure Of Protected Health Information
Medical
Authorization Form For Use Or Disclosure Of Protected Health Information - Sedgwick County, Kansas
Medical
Related Categories
Parent category: Medical