Request for Restrictions on Uses and Disclosures of Protected Health Information

 Request for Restrictions on Uses and Disclosures of Protected Health Information
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Multi-State
Control #:
US-3582
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Description

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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