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.

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.
If using a Chrome Operating System, you must first download and save the form, then re-open it before you can enter data into the fields.
The form can be submitted by email, fax, mail or in person.

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.

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.
If using a Chrome Operating System, you must first download and save the form, then re-open it before you can enter data into the fields.
The form can be submitted by email, fax, mail or in person.