Restrictions Form

 Request for Restrictions on Uses and Disclosures of Protected Health Information
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State:
Multi-State
Control #:
US-3582
Instant Download
Available formats: Word | Rich Text

Free Preview request health information form

Description health information form

This form is used by an individual to request restrictions on the disclosure and use of the individual's protected health information. The individual's rights regarding restricting such use and disclosure are explained, as well as the responsibilities of the record provider in regard to the restrictions.

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