Danville Fire Department
patient Request for Restriction
Danville Fire Department and Center Township / Danville
Ambulance Service
Patient Request for Restriction Form
Patient Name: ___________________________________ Date: _____________
Address: ____________________________________________________________
City: ______________________ State: ______________ Zip Code: _________
Social Security No.: ________________________________
Patient Rights: As a patient, you have the right to request restrictions to the uses and disclosures of your PHI. Danville Fire Department and Center Township / Danville Ambulance Service is not required to agree to any restrictions requested by the patient, however any restrictions agreed to by Danville Fire Department and Center Township / Danville Ambulance Service are binding on Danville Fire Department and Center Township / Danville Ambulance Service.
Please indicate your request for restricted uses and disclosures of your PHI.
Signature ___________________________________ Date
FOR AMBULANCE SERVICE USE ONLY
DATE REC’D _________________________
REQUEST ACCEPTED ________________
REQUEST DENIED ___________________
DATE ________________________________
REVIEWING OFFICIAL _______________
NOTICE TO PT _______________________
COMMENTS: ________________________________________________________________________
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