<p>ROUTE TO: [X] Billing</p><p>The University of Oklahoma Insert Entity Here</p><p>Request for Restrictions on Use and Disclosures of Protected Health Information—George Nigh Rehabilitation Institute NOTICE TO PATIENT: Your request for a restriction on the use and disclosure of your protected health information is applicable only to the information maintained by the George Nigh Rehabilitation Institute. If you would like to request a restriction on the use and disclosure of your protected health information maintained by any other University entity, a separate request must be submitted to that provider. (This request is applicable only to uses and disclosures by the George Nigh Rehabilitation Institute.)</p><p>Patient Name: Date of Birth:</p><p>Patient MR #: Social Security #:</p><p>Patient Address: Address City State Zip I hereby request restrictions on the use and/or disclosure of my protected health information maintained or created by the following providers associated with the George Nigh Rehabilitation Institute:</p><p>Name of Physician or Other Provider Department/ Clinic</p><p>REQUESTED RESTRICTION: Check the box to indicate the type of restriction and then describe the specific restriction. Note: Even if a requested restriction is granted, it cannot prevent complete disclosures, nor will it prevent disclosures required or permitted by law. Disclosures also may be made in case of emergency.</p><p>Treatment: Payment: Health Care Operations:</p><p>Disclosures to a family member or others involved in my care or payment for my care:</p><p>My request applies to: check one and indicate date(s)</p><p>Communications/ documentation about this date of service only (indicate date): , or From this date of service (indicate date): until I indicate otherwise, or From this date: to this date:</p><p>Signature</p><p>Title, if legal representative*</p><p>Date File in Patient Chart HIPAA Document Rev 6/2010 Retain for a minimum of 6 years *May be requested to submit evidence of representative status</p><p>REQUEST REQUEST APPROVED DENIED** Too expensive to accommodate request Administratively impractical to accommodate request* May prevent effective treatment Other:</p><p>By: Signature Title Date **May not deny the request if the request applies to restricting disclosure to a health plan and the disclosure pertains to a service for which payment in full for out-of-pocket amounts due to the provider has been made.</p><p>File in Patient Chart HIPAA Document Rev 6/2010 Retain for a minimum of 6 years</p>