You have the right to request additional restrictions on the way we use and disclose your protected health information for treatment, payment or opera...
Request by person served for additional restrictions on uses and disclosures of protected health information You have the right to request additional restrictions on the way we use and disclose your protected health information for treatment, payment or operations. You may also request limitations on how we disclose information about you to family or friends involved in the services you received. We are not required to agree to your request for a restriction and, in some cases, the restriction you request may not be permitted under law. If we do agree, we will be bound by our agreement unless the information is needed to provide you with emergency care or treatment, or to comply with the law. To request a restriction, please complete and return the form below. Name of person served: __________________________________________________________ Last name First Name Mi Address: ______________________________________________________________________ Phone: ________________________________ (day)
Restriction requested: Please answer the following questions. You may attach a separate page if more space is needed. 1. What information do you want to restrict? ________________________________________ ______________________________________________________________________________ 2. Do you want to limit how we use the information, how we disclose the information, or both? Use only Disclosure only Both use and disclosure 3. When should these restrictions apply (i.e., in what circumstances, to which people or parties, etc.)? ______________________________________________________________________ ______________________________________________________________________________
Please send completed form to: Privacy Officer The Arc of Monroe County 1000 Elmwood Ave, Suite 500 Rochester, NY 14620
Additional restrictions form
1
The Arc of Monroe County, NYSARC, Inc
__________________________________________________ Printed name of person served or personal representative
__________________ Date
__________________________________________________ Signature of person served or personal representative
__________________ Date
__________________________________________________ Description of personal representative’s authority
__________________ Date
For Arc of Monroe County use only Date received: _____/_____/_____ Disposition of request: _____ Granted; _____ Denied; _____ Partially denied Person served notified in writing on this date: _____/_____/_____ Name of staff person processing this request: ______________________________________
