Request for Restriction of Use and Disclosure of Protected Health Information

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)