Free Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Restriction Request, HCF 13159 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Financing HCF 13159 (03/05)

STATE OF WISCONSIN P.L. 104-191

WISCONSIN CHRONIC DISEASE PROGRAM (WCDP)

HIPAA PRIVACY RESTRICTION REQUEST
The Privacy Rule standards of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) P.L. 104-191 require DHFS, as a covered entity, to implement processes that give patients certain rights regarding individually identifiable health information. The information requested on this form is needed to comply with those Privacy Rule requirements. Provision of the information that is requested on this form is voluntary. Although the use of this version of the form is voluntary, all of the information outlined on this form is mandatory. Personally identifiable information requested on this form is mandatory in order to process your request and will only be used for this purpose. INSTRUCTIONS: Mail this completed form to the following address: WCDP Participant Services PO Box 6410 Madison WI 53716 SECTION I RECIPIENT INFORMATION Name Last, First, Middle Initial

WCDP Identification Number

Address Street, City, State, ZIP Code

Telephone Number ( )

SECTION II RESTRICTION POLICY SUMMARY AND REQUEST To exercise your right to request restrictions of the WCDP to use or disclose your protected health information, read the following and complete this form. You have the right to request that the Wisconsin Chronic Disease Program (WCDP) restrict the use or disclosure of your protected health information. The WCDP is under no obligation to agree to your request. If the WCDP does agree with your restriction request, our agreement will be in writing and the WCDP will then restrict the use or disclosure of your protected health information per your request. The WCDP may still use or disclose the restricted information when you authorize us in writing to use or disclose the information, or when the law requires the use or disclosure. You may end the restriction at any time by notifying us in writing. The WCDP may also end the agreement to restrict use or disclosure of your protected health information at any time by notifying you in writing. The termination of the restriction will apply only to your protected health information received after the WCDP has mailed you a letter agreeing to the termination of the restriction. Specify the protected health information you want to restrict:

State the restriction you want to apply to that protected health information:

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WCDP HIPAA Privacy Restriction Request HCF 13159 (03/05)

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SECTION III SIGNATURES Please sign the form and complete the appropriate information. SIGNATURE recipient Date Signed

If this request is from a personal representative on behalf of the recipient, provide a copy of the documentation to support the representation and complete the following: Name Personal Representative Relationship to recipient

SIGNATURE Personal Representative

Date Signed