Right to Request Restrictions. You have the right to request restrictions on certain uses and disclosures of protected health information. However, I am not required to agree to a restriction you request.
Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid for out of pocket. In that case, we are required to honor your request for a restriction.
Right to Request Restrictions. You have the right to request restrictions on certain uses and disclosures of protected health information. However, I am not required to agree to a restriction you request. • Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. On your request, I will send your bills to another address.)
Right to Request Restrictions. You have the right to request a restriction or limitation on the health information about you that we use or disclose. Your request must be in writing. Please be aware that we are not required to agree to your request for restrictions. If we agree to your request for a restriction, we will comply with it unless the information is needed for emergency treatment. For more information about this right, see 45 C.F.R. § 164.522.
Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or healthcare operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. Additionally, you can request restrictions on medical information disclosed to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law, and the information pertains solely to a health care item or service for which you, or person other than the health plan on your behalf, has paid us in full. To request a restriction, you must contact the Privacy Office. This contact information is listed on the last page of this Notice. We are not required to agree to your request. If we agree to your request, we will comply with your request unless the information is needed to provide you emergency treatment. You may terminate the restriction at any time. If we terminate the restriction, we will notify you of the termination. We are not able to terminate or refuse your request for restrictions to disclosures to health plans if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law, and the information pertains solely to a health care item or service for which you, or person other than the health plan on your behalf, has paid us in full.
Right to Request Restrictions. You have the right to request a restriction or limitation on your protected health information that we use or disclose for treatment, payment; or healthcare operations. You also have the right to request a limit on your protected health information that we disclose to someone who is involved in your care or the payment for your care, such as a family member or friend. For example, you could ask that we not use or disclose information about a surgery that you had. We are not required to agree to your request. However, if we do agree to the request, we will honor the restriction until you revoke it, or we notify you. To request restrictions, you must make your request in writing and sent by facsimile to Soberlink Healthcare LLC @ 000-000-0000 Attn: Privacy Officer, by mail to Soberlink Healthcare LLC, Attn: Privacy Officer, 00000 Xxxxx Xxxxxxxxx, #000, Xxxxxxxxxx Xxxxx, XX 00000 or by email to xxxxxxx@xxxxxxxxx.xxx. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply — for example, disclosures to your spouse.
Right to Request Restrictions. You have the right to request a restriction or limitation on the health and financial information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the health and financial information we disclose about you to someone, such as a family member or friend, who is involved in your care or in the payment of your care. For example, you could ask that we not use or disclose information regarding a particular treatment that you received. We are not required to agree to your request. If we do agree, that agreement must be in writing and signed by you and us.
Right to Request Restrictions. You have the right to request that we follow additional, special restrictions when disclosing your information. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment as determined by a doctor. To request restrictions, you must make your request in writing to your service provider. In your request, you must tell us what information you want to limit, the type of limitation, and to whom you want the limitation to apply.
Right to Request Restrictions. You have the right to request restrictions on the ways in which we use and disclose your health information for treatment, payment and health care operations, or disclose this information to disaster relief organizations or individuals who are involved in your care. We do not have to agree to the restrictions you request. You may request a restriction on the use or disclosure of your health information by writing to: Fidelis Care, Member Services, 00-00 Xxxxxx Xxxxxxxxx, Xxxx Xxxx, New York 11374.
Right to Request Restrictions. You have the right to request in writing a restriction or limitation on medical information use or disclose about you. ♥Right to request confidential communication. You have the right to request that communication with you about your medical matters in a certain way or at a certain location. ♥Right to a paper copy of this notice. I will provide you with a copy of this notice upon your request. Your signature and date below acknowledges that you have been provided with this document regarding policies and practices concerning your protected health information (PHI). Your signature below also gives general consent for use or disclosure of your protected health information (PHI) for treatment, payment, and health care operations purposes. Your signature also allows us to leave voicemail messages, text messages at the telephone numbers you provide regarding confirming/changing appointments, questions about insurance, etc. Print Patient Name Patient Signature Date If patient under age-18 or Unable to consent. PRINT parent[s]name/ Sole Legal Guardian If patient under age-18 or Unable to consent. SIGNATURE of parent[s]name/ Sole Legal Guardian Date If Joint Custody of MinorPRINT name of Other/Parent/Other Legal Guardian If Joint Custody of MinorSIGNATURE of Other/Parent/Other Legal Guardian Date BN Counseling, LLC • Tax ID: 00-0000000 • T|000-000-0000 • F|000-000-0000 • xxxxxxx@xxxxxxxxxxxx.xxx 000 Xxxxxxxx Xxxxxxxx, Xxxxx 000, Xxxxxxx Xxxx, XX 00000 • 00 X 00xx Xx, 0xx Xxxxx, Xxxxxxx, XX 00000 ��R E G I S T R A T I O N F O R M 🖐 🎔Client Name: Date of Birth: Age: Partner/ Spouses’ Name: Partner/ Spouses’ Date of Birth: Age: Child’s Name: Xxxxx’s Date of Birth: Age: Child’s Name: Xxxxx’s Date of Birth: Age: Client Address: City: Zip: Home Phone: Cell Phone: Work phone: Email Address: Gender: M F Trans Other: Ethnicity: □AA □White □Latino □Asian □Others: Marital Status: S Domestic Partner M W D Social Security No.: Place of Employment Partner /Spouse Name: Place of Employment Psychiatrist Name & Tel Number: Primary care physician Name & Tel Number: Referred By: May we thank this person for the referral? Yes No Emergency Contact: [Name & Telephone no.] Insurance Information Insurance Company: Insurance ID #: Subscriber’s Name: Date of Birth: Social Security Number: Address (if different from above): Release of Information & Assignment of Benefits I authorize to provide necessary clinical information requested by insurance companies to pay BNCounseling directly. I ...
