Santa Ana California Request for Restrictions on Uses and Disclosures of Protected Health Information
State:
Multi-State
City:
Santa Ana
Control #:
US-3582
Format:
Word;
Rich Text
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.
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