Forms Catalog Document - 912 :-: IHS :-: Request for Restriction(s)

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Request for Restriction(s)

This form is used to request restrictions as how protected health information may be used or disclosed to carry out treatment, payment or health care operations, or disclosed to family members and other involved in my care.

Form #: 912 1
Agency: Department of Health and Human Services
Bureau: Indian Health Service
Common Name: Disclosure Restriction on Health Information

	TYPE	PAGES	SIZE (KB)	CAPABILITY	WHAT'S NEEDED
	Form Only	1	252	[3] Fillable + Printable	Adobe Reader Download
	Form Only	1	45	[3] Fillable + Printable	Other Client Software

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