Request list of disclosures of medical information

What is a restriction to my medical information?

• When a restriction or limitation has been approved based on your request, we cannot use or disclose (share) the specified medical information to the person(s) documented on the form. Health First will make reasonable efforts to comply with your request but are not required to agree to your request.

How do I request a restriction to my medical information?

• You will need to submit a Request for Restriction of Use or Disclosure of Protected Health Information form (pdf). The patient information and the Request Restriction of Use and Disclosure sections will need to be completed. The form must be signed at the bottom and verification of identity is required.
• The form can be submitted by email, fax, mail or in person.
• Email to HIM Integrity Team at HIMIntegrityTeam@HF.org
• Main HIM location addresses and fax numbers are included on the form.
• You may also visit/mail to the other facility HIM location addresses.

What is a request for confidential communication?

• Confidential communication means you would like us to contact you regarding any medical matters, for example, by contacting you at work only or by a preferred mailing address.

How do I request confidential communication?

• You will need to submit a Request for Confidential Communication form (pdf). It's on the same form as the restriction form - the patient information at the top and the Confidential Communication sections will need to be completed. The form must be signed at the bottom and verification of identity is required.
• The form can be submitted by email, fax, mail or in person.
• Email to HIM Integrity Team at HIMIntegrityTeam@HF.org
• Main HIM location addresses and fax numbers are included on the form.
• You may also visit/mail to the other facility HIM location addresses.