Patient Request for Restrictions on Use & Disclosure of PHI (Form #109)

The patient who requested that all or part of his PHI be restricted through use (within your practice) or through disclosure (to outside entities) will complete this form. The patient will provide specific information on WHAT he wants restricted and FROM WHOM. The form, retained in the patient's medical record, allows you to record when and how this request is granted, denied and/or terminated.

• 100 Per Case