Request to Restrict Use & Disclosure of Health Information

The Counseling Center

of Wayne and Holmes Counties

Est. 1953 ~ Over 50 years of service excellence!

Request to Restrict Use & Disclosure of Health Information

SECTION A: Client to complete the following information.

NAME:______________________________________________ BIRTH DATE:_____________________

ADDRESS:____________________________________________________________________________

TELEPHONE:_________________________________________ DATE:___________________________

REQUEST:

I hereby request The Counseling Center to restrict the use and disclosure of the following information:

CLIENT ACKNOWLEDGEMENT OF CONDITIONS OF RESTRICTION

(Client to initial each condition.)

1.  _____ I understand that The Counseling Center is not required to agree to this request for restriction.

2.  _____ I understand that The Counseling Center may agree to only a part of the request for restriction,

                    while denying agreement to the remaining request.

3. _____ I understand that if The Counseling Center agrees to the requested restriction (whether all or in part),

                    then the restriction is in effect until one of the following events occurs:

a.    I agree to or request in writing that the restriction be terminated

b.    The Counseling Center notifies me in writing that it is terminating the agreement to restrict. If The Counseling Center terminates the agreement to restrict, then the termination is effective only with respect to information created or maintained after the date of the restriction

4.  _____ I understand that my restricted health information may be disclosed to provide emergency treatment and that The Counseling Center will not further use or disclose my restricted health information for any other purpose.

5. _____ I understand that I still have a right to access my health information as allowed under applicable law.

6.  _____ I understand that my restricted health information may still be disclosed for public policy purposes as stated in The Counseling Center’s privacy practices.

Signature______________________________________________   Date ________________

Signature of Parent

or Guardian____________________________________________    Date ________________

SECTION B: The Counseling Center to complete the following.

Request for restriction is:                   Accepted          Denied

Comments:

_________________________________________________________    _____________________

Diane S. DeRue, MPA, LSW                                                            Date

Compliance and Privacy Officer

Directions for printing the HIPAA forms.

Click on the Print button in the task bar of your Internet browser. If your print button does not work please us the following steps.

Step 1. Right click on the mouse and in the menu that appears, left click on the "Select All" option.

Step 2. When the text is highlighted, right click on the mouse once again and in the menu that appears, left click on the "Copy" option.

Step 3. Right click on the mouse and in the menu that appears, left click on the "Print" option.

Forms to request changes, corrections and/or copies of your clinical record are also available from the Corporate Compliance and Privacy Officer, Medical Records or any Counseling Center office.