611

Form to request limitations on disclosure of ones PHI

(On your letterhead)

Form to request restrictions on communication and/or disclosure of my personal

healthcare information
I request the following restrictions to the use or disclosure of my personally identifiable health information:
_______________________________________________________

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

____________________________
Printed Name (Client)

________________________________________________

_______________

Signature of client or his or her personal representative

Date

___________________________________________
Printed name of client or personal representative

___________________

Relationship to the client

_______________________________________________________________________
Description of personal representatives authority

Accepted

Refused

Reason(s): ______________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
___________________________
Printed name of Privacy Officer

______________________
Signature

Date

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