IHS912-1 Request for Restrictions

IHS-912-1 (3/06)

DEPARTMENT OF HEALTH AND HUMAN SERVICES

FORM APPROVED: OMB NO. 0917-0030
Expiration Date: xx/xx/xx
See OMB Statement below.

Indian Health Service

REQUEST FOR RESTRICTION(S)
45 CFR 164.522(a)
I understand that I have the right to request restrictions as to how my protected health information may be used or
disclosed to carry out treatment, payment or health care operations, or disclosed to family members and others
involved in my care, and that IHS is not required to agree to the restrictions requested. Even if my request for
restriction is denied, I will generally have an opportunity to agree or object prior to disclosures to persons involved in
my care. If IHS agrees to a requested restriction, it will be binding except in the case of emergency treatment. If
restricted information is released for my emergency treatment, IHS will request the provider to not further use or
disclose that information.
I request the following restriction(s) on the use or disclosure of my protected health information:

SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE
(If Personal Representative, state relationship to patient) or Witness (if signature is thumbprint or mark)

DATE

PROOF
ACCEPTED

If accepted, state which of the restrictions accepted:

DENIED

SIGNATURE OF CEO OR DESIGNEE

DATE

OMB STATEMENT
Public reporting burden for this collection of information is estimated to average 10 minutes per response including time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is
not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden to: Indian Health Service, 801 Thompson Ave., TMP Suite 450, Rockville, MD
20852, RE: PRA 0917-0030. Please DO NOT SEND this form to this address.

PATIENT IDENTIFICATION

NAME (Last, FIrst, MI)

RECORD NUMBER

ADDRESS

CITY/STATE

DATE OF BIRTH

PSC Graphic Arts (301) 443-1090

EF