KARNER PSYCHOLOGICAL ASSOCIATES

FORM TO REQUEST RESTRICTIONS ON COMMUNICATION

AND/OR DISCLOSURE

OF MY PERSONAL HEALTHCARE INFORMATION

TO FAMILY, FRIENDS AND OTHERS

I request the following restrictions to the use or disclosure of my personally identifiable health information:

_____________________________

Printed Name (Client)

___________________________________________________ ________________________

Signature of client or his or her personal representative Date

___________________________________________________ ________________________

Printed name of client or personal representative Relationship to client

____________________________________________________________________________________________

Description of Personal Representative’s Authority

□ Accepted

□ Rejected

Reason(s):

________________________________ _______________________ _____________

Printed Name of Privacy Officer Signature Date

Revised April 14, 2003 form 6