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

Filling out the Request To Restrict Use And Disclosure Of Protected Health Information form is an important step for parents, guardians, or legal representatives to protect the privacy of a client's health information. This guide provides clear, step-by-step instructions on how to complete this form online.

Follow the steps to complete your request efficiently.

1. Press the ‘Get Form’ button to obtain the form and access it in the online editor.
2. Enter the client’s last name, first name, middle initial, address, city, state, ZIP code, client index number (CIN), date of birth, and if applicable, date of death. Ensure that all information is accurate and clearly stated.
3. Provide the information for the parent, guardian, or legal representative, including their last name, first name, middle initial, address, city, state, ZIP code, daytime and evening telephone numbers, email address, and the best hours to reach them.
4. Indicate the legal authority you have to restrict the health information of the client. Check the appropriate box for either parent, conservator, guardian, executor of will, medical power of attorney, or other. It is important to attach the necessary legal documentation verifying your authority.
5. Specify the requested restrictions on the use and disclosure of the client's protected health information for treatment, payment, or healthcare operations. Clearly state any particular persons to whom you do not want information disclosed.
6. Attach a photocopy of an identification form and address verification documentation, such as a utility bill or driver’s license, before proceeding to submit the form.
7. Check the box to confirm that you understand the Department of Health Care Services may not agree to the request, but they will notify you of their response. Then, sign and date the form. If you have not attached identification, ensure your signature is notarized.
8. After completing the form, save any changes, and choose to download, print, or share the form as needed.

Get started by completing your Request To Restrict Use And Disclosure Of Protected Health Information form online today.