Patients, parents, or legal guardians may request to limit the access, use, or disclosure of a patient's protected health information for treatment, payment, or health care operations by completing the form listed below:

Request for Restrictions to the Use and Disclosure of Protected Health Information
PRINTER FRIENDLY
(bilingual English/Spanish)

Request for Restrictions to the Use and Disclosure of Protected Health Information
FILL-IN-THE-BLANK**
(bilingual English/Spanish)

**FILL-IN-THE-BLANK form can be used only if you have Microsoft Word.
You can type your information into the form, then print it.