Free Wisconsin SeniorCare HIPAA Privacy Restriction Request, HCF 13168 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Financing HCF 13168 (Rev. 01/05)

STATE OF WISCONSIN P.L. 104-191

WISCONSIN SENIORCARE

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: Wisconsin SeniorCare Customer Services PO Box 6710 Madison WI 53716-0710 SECTION I RECIPIENT INFORMATION Name Last, First, Middle Initial

SeniorCare 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 SeniorCare to use or disclose your protected health information, read the following and complete this form. You have the right to request that SeniorCare restrict the use or disclosure of your protected health information. SeniorCare is under no obligation to agree to your request. If SeniorCare does agree with your restriction request, our agreement will be in writing and SeniorCare will then restrict the use or disclosure of your protected health information per your request. SeniorCare 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. SeniorCare 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 SeniorCare 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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Wisconsin SeniorCare HIPAA Privacy Restriction Request HCF 13168 (Rev. 01/05)

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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