Form 0917-0030, IHS-912 0917-0030, IHS-912 Request for Restrictions(s)

IHS-912-1 (4/09)

DEPARTMENT OF HEALTH AND HUMAN SERVICES

FORM APPROVED: OMB NO. 0917-0030
Expiration Date: 1/31/2016
See OMB Statement below.

Indian Health Service

REQUEST FOR RESTRICTION(S)
I understand that I have the right to request restriction(s) as to how my protected health information may be used
and/or disclosed to carry out treatment, payment or health care operations, or disclosed to family members and
others involved in my care. I understand that IHS may not be required to agree to the restriction(s) 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
not to further use and/or disclose that information.
I request the following restriction(s) on the use and/or disclosure of my protected health information:

SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE
(If Personal Representative, state relationship to patient)

DATE

SIGNATURE OF WITNESS (If signature of patient is a thumbprint or mark)

DATE

ACCEPTED

If accepted, state which of the restriction(s) 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 Graphics (301) 443-1090

EF