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Part 2, Chapter 7:  Manual Exhibit 2-7-P

Policy and Procedure for Request for Restriction(s) on the use and
Disclosure of Protected Health Information


  1. PURPOSE.  To publish Indian Health Service (IHS) policy and procedure on the rights of patients to request restriction(s) of the use or disclosure of their protected health information (PHI).

  2. AUTHORITY.  45 Code of Federal Regulations (CFR) 164.522(a)

  3. POLICY.  Under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, patients have the right to request restrictions on the use or disclosure of their PHI to carry out treatment, payment and health care operations, inpatient hospital directory, and disclosures to relatives, family members, personal representatives, close friends, health care givers, and any other person involved in the patient’s care or payment who is identified by the patient.

    The IHS is not required to agree to the request.  However, a patient still may object to the disclosure of information for the inpatient hospital directory and to relatives, friends, and others involved in patient care under 45 CFR 164.510(b).  (See Manual Exhibit 2-7-M, “Policy and Procedures for Uses and Disclosures of Protected Health Information for Involvement in the Patient’s Care and for Notification Purposes.”

  4. PROCEDURES.  The following procedures will govern how restrictions will be requested and processed.

    1. The request for restriction must be in writing using form IHS-912-1, “Request for Restriction(s).”  (See Appendix 1.)  The patient is not required to provide a reason for the request.

    2. The Chief Executive Officer (CEO) or his or her designee, in consultation with an appropriate official, must review the request, before the patient is notified of the decision, except for acceptance of the request to omit PHI from hospital directories.  (For Areas that provide Contract Health Service directly through the Area Office, references to the CEO should be considered references to the Area Director’s designee, as applicable.)  The IHS is not required to agree to the requested restriction.  Before agreeing to the restriction, the IHS must attempt to contact the Office of General Counsel.

    3. If the IHS agrees to a restriction, PHI may not be used or disclosed by the IHS or its Contractor(s)(Business Associate(s)) in violation of such restriction, except if the restricted PHI is needed by the IHS or another health care provider to provide emergency treatment of the patient.

    4. If the IHS agrees to a restriction, the Form IHS-912-1 will be processed accordingly and subsequently filed in the medical record.

    5. If the IHS disagrees (or denies) to a restriction, the Form IHS-912-1 will be processed accordingly and subsequently filed in the medical record.

    6. If restricted information is disclosed to a health care provider for emergency treatment, the IHS must request that the receiving health care provider not further use or disclose the PHI, using the following language:

      “This is restricted information, provided for the purpose of emergency treatment, which should not be further disclosed or used without the permission of the patient to whom the information pertains.”

    7. A restriction agreed to by the IHS shall not prevent the use or disclosures for which authorization is not required as outlined in the IHS “Notice,” examples of which may include the following:

      1. to a patient who requests access to their PHI about themselves;

      2. required by the Secretary, Department of Health and Human Services, to investigate or determine compliance by the IHS with the HIPAA Privacy Rule;

      3. for inpatient hospital directory where the patient has not objected to such uses or disclosures;

      4. required by law;

      5. for public health activities;

      6. about victims of abuse, neglect or domestic violence;

      7. for health oversight activities;

      8. for judicial and administrative proceedings;

      9. for law enforcement purposes;

      10. about decedents;

      11. for organ, eye or tissue donation purposes;

      12. for research purposes;

      13. to avert a serious threat to health or safety;

      14. for specialized government functions;

      15. for workers’ compensation.

    8. If the IHS has agreed to a requested restriction, it may terminate its agreement if:

      1. the patient agrees to or requests the termination in writing using the Form IHS 912-2, “Request for Revocation of Restriction(s).”  See Appendix 2; or

      2. The IHS informs the patient that it is terminating the agreement, in which case the termination will be effective with respect to PHI created or received after IHS has so informed the patient.

      3. When the patient is informed that it is terminating the agreement, the method of informing, together with the date and signature of the CEO or designee, shall be noted in the file.

  5. FORMS.  Both Form IHS-912-1 and Form IHS-912-2 are available at:

(For Public and Federal access) http://www.forms.gov/ or http://www.ihs.gov/CIO/puf/

(For IHS staff only) http://intranet.hhs.gov/forms


Manual Exhibit 2-7-P

Appendix 1 and 2

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