HP-2073
CO-06-a | PHI Restriction Request
Revised 08/09/2017
I, _______________________________________, hereby request a restriction be placed on the use and
disclosure of my protected health information for treatment, payment, insurance or health care
operations purposes by Sanford Health Plan.
Please specify the type of restriction(s) you are requesting:
□ All communications
□ Printed communications (mail)
□ Verbal communications (phone)
□ Electronic communication email
□ Other (please specify) _______________________________________
What person(s) or facility(ies) does this restriction apply to?
________________________________________________________________________________________
NOTE: If you maintain a flexible spending account with auto processing (or are a dependent on
a flexible spending account), auto processing will be automatically deactivated to ensure
information is not shared with other members on the policy.
I understand that Sanford Health Plan is not required to agree to my restriction request, but is only
required to attempt to accommodate reasonable requests when appropriate. I further understand
Sanford Health Plan reserves the right to end an agreed-upon restriction if Sanford Health Plan deems
appropriate. I also understand I also have the right to end this restriction by completing a Health
Information Disclosure Form and returning to Sanford Health Plan.
___________________________________________________________
Print Member name
___________________________________________________________________________________________
Name of personal representative (if Member unable to sign) Relationship to Member
___________________________________________________________________________________________
Signature of Member (or Member's representative) Date
Member Health Information
Restriction Request Form
PO Box 91110
Sioux Falls, SD 57109
(877) 305-5463
Fax: (605) 328-6811
sanfordhealthplan.com
INTERNAL USE ONLY
Restriction is _____ Approved _____ Denied _____ Needs review by Health Plan Compliance
Flexible spending auto processing confirmation _____
Comments_____________________________________________________________________________________
Authorized by _________________________________ Department _________________________ Date __________
TERMINATION REQUEST
Terminated by ____Organization ____Member Effective Date____________
Authorized by _______________________ Department _____________________________________
* Attach updated Health Information Disclosure Form to this document.
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signature
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