Restriction of Use or Disclosure of Protected Health Information

Restriction of Use or Disclosure of Protected Health Information (PHI) Policy

Effective April 14, 2003, a patient has the right to REQUEST that the use and disclosure of his protected health information (PHI) be restricted for treatment, payment, and health care operations (TPO), as well as restricting disclosure to only certain people, such as certain family members only. THIS PRACTICE DOES NOT HAVE TO AGREE TO YOUR REQUEST. The restriction request must be in writing, be specific as to what information is covered by the request, whether it covers use, disclosure, or both, and to whom these limitations apply.

If this practice agrees to the request, it will honor the request except when overriding laws or emergencies apply.

Restriction of Use or Disclosure of Protected Health Information (PHI) Form

I, _______________________________________, request that Brett Elliott, M.D. P.A. restrict the use or

disclosure of my ____________________________________________________________________ to

___________________________________________________________________________________.

Patient Signature:__________________________________ Date: ___________

Privacy Officer Comments:

___ Accept this request.

___ Reject this request

__________________________________________________________________________________________________________________________

___ Patient contacted: ___________________________________________________________________________

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This page was last updated on 4/10/03