Valdosta State University

Request For Limitations and Restrictions of
Protected Health Information

* Speech Clinic

* Student Health Services

* Athletic Department

* Human Resources

* Other. Please Specify ___________________________________________

PATIENT/EMPLOYEE PLEASE NOTE:

VALDOSTA STATE UNIVERSITY IS NOT REQUIRED TO AGREE TO YOUR REQUEST. PLEASE SEE OUR NOTICE OF PRIVACY VALDOSTA STATE UNIVERSITY FOR MORE INFORMATION REGARDING SUCH REQUESTS.

Patient/Employee Name:________________________ Date of Birth:_________________________

Patient/Employee Address:

                        ___________________________________

                        Street

                                ________________________________________

Apartment #

                                ________________________________________

                                City, State Zip

Type of PHI to be restricted or limited: (Please check all that apply)

               Home phone #                                       * Patient/Employee history

               Home address                                            * Office address

Occupation                                                 * Office telephone number

               Name of employer                                     * Spouse's name                               

               Visit notes                                                   * Spouse's office telephone number

               Hospital notes                                            * Other______________________

               Prescription information

How would you like use and (or disclosure of) your PHI restricted?

________________________________________                   _____________________________

Signature of Patient/Employee or Legal Guardian                                      Date

FOR INTERNAL PURPOSES ONLY:

Date Request Received:____________