Form #6 - REQUEST FOR SPECIAL RESTRICTION ON THE USE AND DISCLOSURE OF PHI : Torrance Memorial Medical Center

REQUEST FOR SPECIAL RESTRICTION ON THE USE AND DISCLOSURE OF PHI - Form #6

I understand that Torrance Memorial Medical Center may use or disclose my protected health information ("PHI") for the purposes of treatment, payment and health care operations. Torrance Memorial Medical Center may also disclose information to someone involved in my care or the payment for my care, such as a family member or friend. I understand that Torrance Memorial Medical Center does not have to agree to my request for a restriction.

I hereby request a restriction on the hospital's use or disclosure of protected health information FOR THIS VISIT ONLY. This restriction will automatically terminate when I am discharged from the hospital, after my outpatient visit or after my course of care is finished. The information I want restricted is:

	Make me a "confidential" patient. I will not receive mail, email, phone calls, visitors, clergy or deliveries (flowers, gifts, etc.) I will not be overhead paged. (No Publish)
	I wish to restrict all phone calls only - (check box or notify your nurse after you are admitted, (Do Not Disturb))
	I wish to restrict clergy visits only - you must choose "no clergy" as religion type (check this box or notify your nurse after you are admitted (Religion Field No Clergy)).
	I wish to restrict the discussion of the following condition with the listed person: (Clinical Staff).

Condition:	Person to be Resticted:

Signature of Patient or Representative:
Print Patient Name or Representative:
If Representative, give relationship:	Date:

Torrance Memorial Medical Center Acceptance of Restriction

Torrance Memorial Medical Center Respresenative Signature:

Date:

This restriction may be terminated if I orally agree to the termination and the oral agreement is documented by my nurse.

To be used after admission:
Restriction terminated	Date:	Time:
Patient Signature:	Staff Signature:

REQUEST FOR SPECIAL RESTRICTION ON THE USE AND DISCLOSURE OF PHI
HIPAA FORM #6 Page 1 of 1

Addressograph

If restriction is requested after admission, tube a copy to Admitting and fax a copy to PBX.