0130.005.00 Confidentiality

0130.005.10.15 Client Requests to Restrict the Use and Disclosure of Protected Health Information

Clients have the right to request specific restrictions on the use or disclosure of PHI. Claimants must file this request in writing. Staff must send the completed request to the FSD privacy officer. The privacy officer will then determine whether to accept or deny the request.

  1. Requesting the Restriction: Clients must indicate their request for restriction by using the DSS Request for Restriction of Information form. The form must be completed, signed and dated by the client or his or her personal representative.
  2. Agreement or Denial of the Request: The FSD Privacy Officer must receive the written request and determine whether it will be approved. The privacy officer will provide staff and the client with the final decision.
    • If approved, staff must implement the restriction and ensure that such protected information is easily identifiable in the client’s record to avoid possible use or disclosure. Examples include recording the restriction on the IM-61 form or the IM-61B form, or by attaching a cover sheet.
    • If denied, do not implement the client’s request for the restriction.
    • File the original in the front of medical record section if the request concerns those records, or file it in the front of the client case next to the Change of Status Summary form.
  3. Termination of Restriction: If the client wants to terminate the approved restriction, have the client to complete a Request for Restriction of Information form and to indicate the request for termination of the restriction. Send the request to the FSD privacy officer. After a client has terminated the restriction, the privacy officer will sign and date the form, and return a copy to staff for implementation.