Saint Therese Home, Inc.
REQUEST TO RESTRICT USE OR
DISCLOSURE OF HEALTH INFORMATION
Resident Name ________________________ Medical Record #_____________________
Other Name(s) ____________ DOB _______ Social Security #______________________
I request a restriction on the following concerning my personal health information as described below:
q Use
q Disclosure
q Both the use and disclosure
I would like to have the following personal health information restricted: ____________________________________________________________________________________________________________________________________________________________
I would like the facility to restrict the use and/or disclosure of the health information described above in the following manner: (i.e. limitation on who receives the information, limitation on the nature of the information disclosed, etc.) Requested restrictions may include uses or disclosures relating to treatment, payment or health care operation or relating to other persons involved in my care: ____________________________________________________________________________________________________________________________________________________________
I understand that St. Therese is required to agree to my request to restrict use or disclosure of information, except when my records are released in connection with my transfer to another health care institution or when the use or disclosure of the information is required by law. I also understand that if I request a restriction, the restriction will not apply if the information is needed to provide me with emergency treatment.
Please allow staff three days to
complete request
_______________________________________ ___________________________________
Signature
of Resident/Responsible Party Relationship
to Resident if Signed by Res. Party
__________________________________________ ______________________________________
Date of Resident’s/Responsible Party’s Signature Reason Resident Unable to Sign