08/05/2019
PHI12/R11
ENR-1710-PHI12
GE-FRM-0119-002
0I
REQUEST FOR RESTRICTION
Use this form to request that GEHA restrict the uses or disclosures of your protected health
information (“PHI”).
About you, the GEHA member whose PHI is to be restricted
Plan ID Number:
Member Name: _______ Date of Birth: _______________________
Address:
Telephone Number:
Please place a check mark in front of each plan you want this Access request to be applied:
___ GEHA Health Plan ___GEHA Connection Dental Federal Plan
___ Connection Dental Plus Plan ___CONNECTION Vision Plan
Restriction Information
Do not release information specified below to:
Information:
Reason:
Signature and Acknowledgement
• I understand that any request GEHA accepts will be limited to information under GEHA’s control, and the request
will be communicated to GEHA’s Business Associates.
• I understand GEHA is not required to accept my restriction request.
• In some cases, GEHA has the right to terminate agreed upon restrictions. If it does so, GEHA will inform you of
the termination in writing. Any such termination will only apply to information created or received after we have
informed you of the termination.
• I have the right to request GEHA terminate the restriction understanding the termination will apply to information
created or received after the date of termination, by contacting the Privacy Office at the address below.
Date:
Patient or Legal Representative Signature:
Relationship to patient:
(i.e. parent, legal guardian, power of attorney, etc.)
NOTE: If the signature is not that of the patient or the parent when the child is a minor, appropriate legal documentation
is required to accept the signature.
click to sign
signature
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