Get Request To Restrict Use And Disclosure Of Protected Health Information By Parent, Guardian Or Legal

Filling out the request to restrict use and disclosure of protected health information is an important process for parents, guardians, or legal representatives. This guide provides clear, step-by-step instructions to help you complete the form accurately and submit it online with confidence.

Follow the steps to effectively complete your request online.

1. Press the ‘Get Form’ button to access the request form and open it in your preferred online editor.
2. Provide the client’s information in the designated fields. This includes the last name, first name, address, city/state, client index number, date of birth, and if applicable, date of death. Ensure all entries are accurate and complete.
3. Enter your information as the parent, guardian, or legal representative. Fill in your last name, first name, middle initial, address, city/state, zip code, daytime and evening telephone numbers, email address, and the best hours to reach you.
4. Indicate your legal authority to restrict the health information of the client by checking the appropriate box. Provide any necessary legal documentation that verifies your status.
5. Specify the requested restrictions by detailing which aspects of the client's protected health information you wish to restrict in treatment, payment, or healthcare operations.
6. List any individuals, including family members or friends, to whom you do not want the Department of Health Care Services to disclose information. Include their names and relationships.
7. Attach a copy of your identification, noting the type and number of that identification. Make sure to also include any necessary address verification.
8. Review the form for accuracy, then provide your signature along with the date. If no identification is attached, ensure that your signature is notarized.
9. After completing the form, save your changes. You can then download, print, or share the form as needed.

Start filling out your request form online to protect the privacy of your loved ones' health information today.