Mesa Arizona Solicitud de Restricciones de Usos y Divulgaciones de Información de Salud Protegida - Request for Restrictions on Uses and Disclosures of Protected Health Information
State:
Multi-State
City:
Mesa
Control #:
US-3582
Format:
Word
Instant download
Description
This form is used by an individual to request restrictions on the disclosure and use of the individual's protected health information. The individual's rights regarding restricting such use and disclosure are explained, as well as the responsibilities of the record provider in regard to the restrictions.
Para su conveniencia, debajo del texto en español le brindamos la versión completa de este formulario en inglés.
For your convenience, the complete English version of this form is attached below the Spanish version.
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