Request for Restriction of Use and Disclosure of Protected Health Information

Request for Restriction of Use and Disclosure of Protected Health Information
Hey Jane Health members have the right to request that Hey Jane Health restrict the use or disclosure of health information for certain aspects of treatment, payment, or health care operations.

Members also have a right to request that Hey Jane Health restrict the disclosure of their health information to family members and others involved in their care. Hey Jane Health will consider all requests for restrictions carefully; however, Hey Jane Health is not required to agree to a requested restriction.
Part 1: Member Information

This section should name the Hey Jane Health member whose PHI is requested. Print the member’s name, birth date, address, telephone number.
Name *

First Name Last Name
Birth date *

Month Day Year
Date
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Part 2: Restriction

In this section provide information about the restriction you would like to take place.
Describe the protected health information to be restricted. *
State the restriction you want to apply to the PHI. *
State persons/organization restricted from uses/disclosure. *
Part 3: Review and Approval

The member’s signature is required. If the member is incapable of signing, a personal representative may sign on the member’s behalf. Parents or guardians of minors will be confirmed using information from the state. A personal representative such as an executor or someone with a power of attorney may sign his or her name in the member’s place. The legal documents proving the authority of the personal representative to act for the member MUST be attached or on file at HPP; otherwise the personal representative’s signature will be invalid and this form will NOT be processed.
You have the right to request that Hey Jane Health restrict its use of your PHI to what is necessary for the provision of health care or payment of claims. If Hey Jane Health grants your request, you will be notified in writing. Hey Jane Health may use or disclose the restricted information when needed to treat you in a medical emergency or when required or authorized by law. You may end a restriction agreement at any time by notifying Hey Jane Health in writing. Restrictions will expire for minors when they reach the age of maturity (18 years of age).

I have read and understand the above information:
Print Name *

First Name Last Name
Signature *

Clear
Date Signed *

Month Day Year
Date
Should be Empty:

Request for Restriction of Use and Disclosure of Protected Health Information

Part 1: Member Information

Part 2: Restriction

Part 3: Review and Approval