Requests for Restricting Uses and Disclosures of Protected Health Information and Confidential Communications

Requests for Restricting Uses and Disclosures of Protected Health Information and Confidential Communications
Request Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
- Patient Name
  
  First NameMiddle NameLast Name
- Date of Birth
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Patient Representative (Power of Attorney or Legal Guardian)
  
  First NameMiddle NameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number
  Format: (000) 000-0000.
- Email Address
- You have the right to request that Corstrata, Inc. and/or Corstrata Nursing Services, PC (“Corstrata”), restricts uses and disclosures of your protected health information (“PHI”) for treatment, payment, and healthcare operations purposes. For example, you may request that we not disclose PHI to a family member. You also have the right to request that we communicate with you in an alternative manner and at an alternative address. For example, you may want us to always send your PHI to you at a different location. In making these requests, please be aware of the following information:
  - Corstrata is not required to agree to your request. We will review your request and determine if we are administratively able to agree to it. We will provide you with our decision in writing
  - Any restriction we accept will be limited to information under our control. For example, this does not apply to health information maintained by your insurance company or other providers
  - Requests to not bill your insurer require that:
    
    Payment be made in full prior to any consultation
    
    You are not a Medicare or Medicaid beneficiary regarding a service covered by Medicare or Medicaid
    
    The service is not related to a Worker’s Compensation claim
- I request that Corstrata restricts disclosures of the following PHI about me:
- I request that Corstrata restricts disclosures of the above PHI to the following people or for the following purpose:
- I request that Corstrata communicate with me in the alternative manner:
- Reason for my request:
- Print Full Name
- Completed/Signed by:
- Signature
- Please attach a copy of your government-issued ID. If signed by Patient Representative, provide relationship to the patient and proof of Legal Representation
  
  Cancelof
- Corstrata, Inc.
  Privacy Officer
  P.O. Box 30643
  Savannah, GA 31410
  Phone #: (800) 566-1307
  Fax #: (855) 236-5024
  Email: Privacy@Corstrata.com
- Should be Empty: