Restriction on Use and/or Disclosure of Health Information Request Form

Patient Information

Name:

Date of birth:

SSN:

Phone:

Current Address:

City:

State:

ZIP Code:

Request Date:

Person Requesting Restriction on Use and/or Disclosure

Name:

Street Address:

Phone:

City:

State:

Zip Code:

Relationship to Patient:

Restriction on Use and/or Disclosure Request

Please describe specifically the health information at issue and how specifically you would like to restrict its use or disclosure:

Patient of Patient or Patient’s Representative:

Date:

FOR MYLES AND ASSOCIATES INTERNAL USE ONLY

Date Received:

Accepted

Denied

If denied, list reason(s) for denial (note: may not deny request to restrict disclosure to insurer if patient is self-pay)

Individual was informed of the acceptance or denial in writing

Signature of Myles and Associates Representative:

Date:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature:

Your information will be encrypted.