To:

I reject the government’s claim that citizens have a public responsibility to disclose private and personal medical information as stated in the medical privacy recommendations written by the U.S. Department of Health and Human Services (9/11/97).

I also find the federally permitted use and disclosure of personal, medical and health data by various institutions, corporations, and individuals under the Health Insurance Portability and Accountability Act (Public Law 104-191-August 21 1996) and the subsequent federal medical privacy rule (Standards for Privacy of Individually Identifiable Health Information, 45 CFR Parts 160 and 164) to be detrimental to medical privacy and the confidentiality of medical records and individually-identifiable health data. The federal medical privacy rule took effective April 14, 2001 with implementation and enforcement set for April 14, 2003. Only stricter state medical privacy laws can supersede the requirements of the federal rule.

For the record, I therefore and hereby declare my express wish and intent for the truly confidential treatment of medical records, health information, psychological testing, genetic testing, and all other information received, heard, said, written, or stored in the course of interactions with the above named person/corporation/agency. Please keep this form on file. To be specific, without written, specific, informed and voluntary consent, I ask you (the above) not to disclose, sell, or otherwise release, to the following agencies/groups or for the following purposes (as checked below), the personal, medical, psychological, financial, genetic, demographic, or health data, or body parts and tissues of ________________________________________ (Name of self, child, or guardian responsibility).

Payment and Treatment  Health care operations  Hospital and facility patient directories  Public safety  Environmental Protection Agency  Central Intelligence Agency  National Transportation Safety Board  Food and Drug Administration  Occupational Safety & Health Admin.  State departments of health  Medical or other review boards  Federal Bureau of Investigation  Departments of agriculture  Mine Safety and Health Administration  Government oversight agencies  Community agencies/groups  Government welfare departments  Government education agencies  Government human services departments  Government contractors  Any government agency/department  Foreign governments/organizations.  Fundraising

Newborn metabolic testing data collection  Birth defect registries/data collection  Immunization registries/data collection  Cancer registries/data collection  Public health surveillance  Workforce/Injury data collection  Indian health registries  Minority, race, or health disparities databases  Newborn hearing screening database  Genetic testing/DNA databases  Medical error reporting systems  Private registries/data collections  Health status databases  OASIS - home health database/collection  Computerized smart cards  Disease-specific organizations  Centers for Disease Control & Prevention  U.S. Dept. of Health and Human Services  Pharmaceutical benefit management co.  Disease management companies  Tissue or organ donation organizations  Public health agencies/officials  Any government database/data collection

Law enforcement officers/agencies  Public policy researchers  National security  Medical/Scientific researchers  Peer review organizations  Certification processes  Marketing of services or products  Accreditation and licensing  Clinical guideline development  Training programs  Social service agencies  Pharmaceutical companies  Litigation/Lawyers  Judges/Administrative law staff  Members of the clergy  Coroners/Medical examiners  State fire marshals  Health boards  State or other ombudsman  Workman’s Compensation  Banks/credit card payments  Media/Press/News Services  Other___________________

This restriction on data disclosure, use and access shall be valid until otherwise removed by written authorization of the subject (or parent or guardian of subject if subject is a minor or under guardianship) of the information.

Signature	Relationship to Above Person	Date
Printed Full Name
Address	City / State	Zip code

CCHC DISCLAIMER: CCHC is a non-profit 501(c)3 organization. CCHC provides this form only as information to assist individuals in restricting access to or use of their individually identifiable medical or financial information. CCHC specifically does not warrant the effectiveness of said form in restricting access to or use of personal information by government agencies or private organizations. CCHC is not liable for any injury, either in whole or in part, caused, directly or indirectly, by use of this form. With the advice to the user that under the law this form may not be binding, it does however express your desire for medical, financial and personal privacy. It also expresses your protest if your medical records and other personal information are accessed, used or disclosed without your written, informed and voluntary consent.