You can use this form when you want to manage who can and can’t see your protected health information.

What you’ll need:

  • Your subscriber ID card, also known as enrollee ID card
  • A printer to print the form
  • An envelope and postage to mail the form, or a fax machine. Each form includes instructions, a mailing address and a fax number.

If you have any questions, please contact us.

Request for Restriction of Use and Disclosure of Protected Health Information (PDF)