HACKENSACK UNIVERSITY MEDICAL CENTER
COUNTY OF SAN DIEGO
REQUEST FOR RESTRICTIONS ON USES AND DISCLOSURES
OF PROTECTED HEALTH INFORMATION
I hereby request that the County restrict use and disclosure of my health information as described below.
| |Date: |
| | |
|PATIENT/RESIDENT/CLIENT |
|Last Name: |First Name: |Middle Initial: |
| | | |
|Address |City/State: |Zip Code: |
| | | |
|Telephone Number: |SSN (Optional): |Date of Birth: |
| | | |
|AKA’s: |
| |
|I AM REQUESTING THE FOLLOWING RESTRICTIONS ON THE USE AND DISCLOSURE OF INFORMATION CONTAINED IN MY MEDICAL OR BILLING RECORDS: |
| |
|PATIENT RIGHTS |
| |
|I understand I have the right to request a restriction on how my health information is used or disclosed. I may request restriction of uses and disclosures of my |
|protected health information to carry out treatment, payment, and health care operations, disclosures to a family member, other relative, close personal friend, |
|or any other person involved in my care, and disclosures of protected health information to notify, or assist in the notification of a family member, a personal |
|representative, or another person responsible for my care, of my location, general condition, or health. I understand that my request must be submitted in |
|writing. |
|COUNTY RESPONSIBILITIES |
| |
|The County is not required to grant any restrictions and cannot grant any restrictions that would violate the law. A decision regarding the request will be |
|rendered within a reasonable time period. If the request is granted, the County must abide by the restrictions unless I agree to terminate the restriction or the |
|County tells me it is terminating the original agreement. I understand the County may disregard the restriction agreement without my approval if I am in need of |
|emergency treatment and the restricted information is needed to provide the emergency treatment. |
|QUESTIONS |
|If you have any questions regarding restrictions of your health information, please contact: |
| |
|Privacy Officer |
|County of San Diego Compliance Office |
|P.O. Box 85524 (Mail Stop: P501) |
|San Diego, CA 92186-5524 |
|(619) 515-4244 |
|SIGNATURE OF INDIVIDUAL OR LEGAL REPRESENTATIVE |
|Signature: |Date: |
| | |
|If Signed by Legal Representative, Relationship to Individual: |
| |
| |
| |
|THIS SECTION IS FOR COUNTY USE ONLY |
|The above request for restriction of health information by the above named individual has been: |
| |
|Granted __________ Denied___________ |
| |
|Reason(s) for Denial, if Applicable ____________________________________________________ |
| |
|________________________________________________________________________________ |
| |
|________________________________________________________________________________ |
| |
|________________________________________________________________________________ |
| |
| |
|________________________________________ ___________________ |
|County Privacy Officer Date |
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- navneet kathuria md mph mba hfma nj
- the alara group
- the center for cognitive studies
- nutley school district verona public schools
- firstchoice obstetrics gynecology group llc
- rutgers university
- march 28 2005 california state university fresno
- hackensack university medical center
- university curriculum vitae format
Related searches
- hackensack university medical center jobs
- hackensack university medical center intr
- hackensack university medical center dire
- hackensack university medical center map
- hackensack university medical center billing
- hackensack university medical center email
- hackensack university medical center my chart
- hackensack university medical center directory
- hackensack university medical center records
- hackensack university medical center nj
- hackensack university medical center hackensack nj
- hackensack university medical center medical records