DOEA Form 183 "Request for Restriction on Use & Disclosure of Medical Information and/or Confidential Communication" - Florida

What Is DOEA Form 183?

This is a legal form that was released by the Florida Department of Elder Affairs - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2003;
  • The latest edition provided by the Florida Department of Elder Affairs;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DOEA Form 183 by clicking the link below or browse more documents and templates provided by the Florida Department of Elder Affairs.

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Download DOEA Form 183 "Request for Restriction on Use & Disclosure of Medical Information and/or Confidential Communication" - Florida

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REQUEST FOR RESTRICTION ON USE & DISCLOSURE OF
MEDICAL INFORMATION AND/OR CONFIDENTIAL COMMUNICATION
FLORIDA DEPARTMENT OF ELDER AFFAIRS
4040 ESPLANADE WAY
TALLAHASSEE, FLORIDA 32399-7000
Client Name: ______________________________________________________________
Phone Number (Day): _____________________________
Phone Number (Evening): __________________________
Street or PO Box: _________________________________
City: ____________________________________________
State: ___________________________________________
Zip: ____________________
1) Medical Information to be Restricted:
2) Nature of Restriction:
3) Medical Information to be Communicated Confidentially:
4) Alternative Location/Address/Telephone Number/E-mail:
TO OUR CLIENTS: You have the right to request that we restrict our use and disclosure of your
medical records and information. We do not have to agree to your requested restrictions. If we do
agree to the requested restriction, we will abide by the restriction unless a medical emergency
requires otherwise. You also have the right to request that we communicate certain medical
information to you in confidence. We will accommodate reasonable written requests to receive
communications of medical information by alternative means or at alternative locations only if you
(1) specify the alternative location, address, or telephone number and/or the alternative means of
contact and (2) agree to be responsible for and explain how payment will be handled for any
additional costs associated with the alternative method of communication.
By your signature below, you acknowledge that you understand and agree to the above
information.
Signature of Client: ____________________________________________________________
Date:______________________
DOEA Form 183 (04/03)
Page 1 of 2
REQUEST FOR RESTRICTION ON USE & DISCLOSURE OF
MEDICAL INFORMATION AND/OR CONFIDENTIAL COMMUNICATION
FLORIDA DEPARTMENT OF ELDER AFFAIRS
4040 ESPLANADE WAY
TALLAHASSEE, FLORIDA 32399-7000
Client Name: ______________________________________________________________
Phone Number (Day): _____________________________
Phone Number (Evening): __________________________
Street or PO Box: _________________________________
City: ____________________________________________
State: ___________________________________________
Zip: ____________________
1) Medical Information to be Restricted:
2) Nature of Restriction:
3) Medical Information to be Communicated Confidentially:
4) Alternative Location/Address/Telephone Number/E-mail:
TO OUR CLIENTS: You have the right to request that we restrict our use and disclosure of your
medical records and information. We do not have to agree to your requested restrictions. If we do
agree to the requested restriction, we will abide by the restriction unless a medical emergency
requires otherwise. You also have the right to request that we communicate certain medical
information to you in confidence. We will accommodate reasonable written requests to receive
communications of medical information by alternative means or at alternative locations only if you
(1) specify the alternative location, address, or telephone number and/or the alternative means of
contact and (2) agree to be responsible for and explain how payment will be handled for any
additional costs associated with the alternative method of communication.
By your signature below, you acknowledge that you understand and agree to the above
information.
Signature of Client: ____________________________________________________________
Date:______________________
DOEA Form 183 (04/03)
Page 1 of 2
REQUEST FOR RESTRICTION ON USE & DISCLOSURE OF
MEDICAL INFORMATION AND/OR CONFIDENTIAL COMMUNICATION
Client Name: ______________________________________________________________
Case Manager Name: ________________________________________________________
Request for Restriction Accepted ________________
Request for Restriction Denied __________________
Request to Communicate Confidentiality Accepted ___________________
Request to Communicate Confidentiality Denied _____________________
This Request for Restriction and Confidential Communication Form is to be made a part of the
medical record of: (Client Name) _______________________________________________
DOEA Form 183 (04/03)
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