REQUEST TO RESTRICT USE & DISCLOSURE

OF HEALTH INFORMATION

SECTION A: Client to complete the following information.

DATE: __________________________

Client NAME: ______________________________ BIRTH DATE: _______________

Client ADDRESS:

______________________________________________________________________

Client TELEPHONE NO.:_________________________

REQUEST:

I hereby request HDC to restrict the use and disclosure of the following information (check all that apply):

  Restrict uses and disclosures of health information for purposes of treatment, payment,

or health care operations.

  Restrict disclosures to a family member, relative, or close personal friend who is

involved with my health care. Please specify individual(s) to whom this restriction applies:

_____________________________________________________________________
_____________________________________________________________________

  Restrict disclosures to a family member, personal representative, or other person

involved in my care for purposes of location, general condition, or death.

Client ACKNOWLEDGEMENT OF CONDITIONS OF RESTRICTION (Client to initial each condition)

  1. _____ I understand that HDC is not required to agree to this request for restriction.

  2. _____ I understand that HDC may agree to only a part of the request for restriction, while

    denying agreement to the remaining request.

  3. _____ I understand that, if HDC agrees to the requested restriction (whether all or in part), then the restriction is in effect until one of the following events occurs:

    1.     I agree to or request in writing that the restriction be terminated

    2.     HDC notifies me in writing that it is terminating the agreement to restrict. If HDC terminates the agreement to restrict, then the termination is effective only with respect to information created or maintained after the date of the restriction 27

  1. _____ I understand that my restricted health information may be disclosed to provide emergency treatment and that HDC will not further use or disclose my restricted health information for any other purpose.

  2. _____ I understand that I still have a right to access my health information as allowed under applicable law.

  3. _____ I understand that I may receive an accounting of disclosures as explained in HDC's notice of privacy practices.

  4. _____ I understand that my restricted health information may still be disclosed for public policy purposes as stated in the HDC's Notice of Privacy Practices.

NOTICE TO Client/OTHERS:

You do have a right to file a complaint with and may do so by contacting the Privacy Officer as follows:

Privacy Officer/HDC

(813) 872-6250

FAX: (813) 872-6278

5904 N. Armenia Ave

Tampa, FL 33603

You also have the right to file a complaint with the Secretary of the federal Department of Health and Human Services, you can address your complaint to 200 Independence Avenue, S.W.; Washington, DC 20201, or reach the Secretary by phone at (202) 690-7000.

SECTION B: HDC to complete the following.

Request for restriction is:         Accepted  Denied

Staff comments

___________________________________________________________________________
___________________________________________________________________________ 
___________________________________________________________________________
___________________________________________________________________________

Signature of staff person _____________________________    Date _________________

Print name and title

___________________________________________________________________________

Signature of Chief Privacy Officer: __________________________ Date ______________

Print name and title

__________________________________________________________________________

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