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    Request For Non-Disclosure of Health Information To Health Plan

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    cig3f
    This document is a form for patients to request non-disclosure of their health information to their health plan. By filling out the form, patients can request that the University of Virginia Health System restrict sharing information about an upcoming medical service with the patient's health insurance plan if the patient intends to pay for the service out of pocket. Key details include requirements for the patient to pay in full prior to the service and acknowledgement that some external services like labs may still bill insurance.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Request For Non-Disclosure of Health Information To Health Plan

    Uploaded by

    cig3f
    21 views1 page
    This document is a form for patients to request non-disclosure of their health information to their health plan. By filling out the form, patients can request that the University of Virginia Health System restrict sharing information about an upcoming medical service with the patient's health insurance plan if the patient intends to pay for the service out of pocket. Key details include requirements for the patient to pay in full prior to the service and acknowledgement that some external services like labs may still bill insurance.

    Original Title

    100367_Request for Non-Disclosure of Health Information to Health Plan

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    This document is a form for patients to request non-disclosure of their health information to their health plan. By filling out the form, patients can request that the University of Virginia Health System restrict sharing information about an upcoming medical service with the patient's health insurance plan if the patient intends to pay for the service out of pocket. Key details include requirements for the patient to pay in full prior to the service and acknowledgement that some external services like labs may still bill insurance.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    21 views1 page

    Request For Non-Disclosure of Health Information To Health Plan

    Uploaded by

    cig3f
    This document is a form for patients to request non-disclosure of their health information to their health plan. By filling out the form, patients can request that the University of Virginia Health System restrict sharing information about an upcoming medical service with the patient's health insurance plan if the patient intends to pay for the service out of pocket. Key details include requirements for the patient to pay in full prior to the service and acknowledgement that some external services like labs may still bill insurance.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    UNIVERSITY OF VIRGINIA HEA LTH SYSTEM PLACE LABEL HERE

    2700002
    FORM NO. 100367

    IF LABEL NOT AVAILABLE, WRITE IN PT NAME & MR#

    HIPAA REQUEST FOR NON DISCLOSURE TO HEALTH PLAN

    REQUEST FOR NON-DISCLOSURE OF HEALTH INFORMATION TO HEALTH PLAN

    Patients have the right to request a restriction or limitation on use or disclosure of their medical
    information to a health plan if paying for health services out of pocket in full. To make this request, please
    complete this form and return it to a scheduling or registration staff member.

    (Patient’s full name) Birth date (Mo/Day/Yr)

    (Street address) Medical Record Number

    (City, state, zip code) Phone

    I, , hereby request the University of Virginia Health System to restrict


    the use or disclosure of my protected health information to my health plan involved in the payment of my
    care for services paid out of pocket in full (based on the full cost estimate) prior to the service being
    provided as specified below. I understand that:
    • I am required to pay, in-full, the projected amount for my services before they occur or this request will be
    null and void and my insurance may be billed without notice and I may be billed for any additional charges
    that must be paid within forty-five (45) days of my service
    • If applicable, I will need to ask my prescribing provider to provide me with a paper prescription to ensure
    that my medication is not billed or disclosed to my health plan
    • Some lab tests are done by an external vendor and I may have to contact one of them to obtain a restriction
    from their billing.
    • This restriction request covers only the encounter specified below. If I want information from other dates of
    service restricted, I will need to fill out another form for each visit.

    Name of Health Plan:


    Date of Service: Department:
    Reason for visit:

    Acknowledgement: By submitting this form, I hereby request the University of Virginia Health System to
    restrict uses and disclosures of my health information as described above. I understand and acknowledge
    that the above stated organization is not required to agree to my request.

    Print name of Patient or Legal Representative Relationship to Patient

    Signature of Patient or Legal Representative Date

    FORM # 100367 (REV. 11/2018) 1 OF 1

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