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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations and
staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Policy Title: Patient Request to Restrict Use and/or Disclosures of Protected
Health Information (PHI)
Policy Number: 6.48
Effective Date: October 1, 2016
Chapter: Health Information Management
This policy outlines: (1) the procedure for reviewing a patient’s request to restrict the use and/or
disclosure of PHI, (2) the process for accepting or denying such requests, and (3) the required
documentation that must be created and maintained related to such requests.
Protected Health Information (PHI): Individually identifiable health information that is transmitted or
stored in any form, including oral, written, and electronic means. PHI includes demographic, health, and
III. POLICY ELEMENTS
UW Health is committed to safeguarding the privacy and security of PHI and recognizing patient rights
with respect to PHI. Patients may submit a written request to restrict: (1) the ways in which UW Health
may use and/or disclose PHI for purposes of treatment, payment, and/or health care operations, and/or (2)
UW Health’s ability to disclose PHI to family members, friends, and others involved in the patient’s care.
UW Health will consider such requests, approve or deny the requests, and document the disposition of the
requests in the patient’s health care record.
1. UW Health shall inform patients of their right to request restrictions in the UW Health
Notice of Privacy Practices.
2. Requests for restrictions must be in writing and submitted to UW Health – Health
Information Management (HIM). The UW Health “Patient Request to Restrict Use and/or
Disclosure of Health Information” form must be used to document such a request.
3. All requests for restriction must be forwarded to HIM for review and final disposition.
HIM may consider a variety of factors in deciding whether to grant or deny a request for
restriction, including, but not limited to: (1) the potential impact of the restriction on
treatment, including coordination of care, and (2) UW Health’s ability to implement and
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comply with the requested restriction. Except for self-pay encounters as described in
Section IV (A) (4), UW Health may deny a request for restriction for any reason.
4. Approval of a Request for Restriction for Self-Pay Services-If the patient, or another
individual on behalf of the patient, pays for a health care item or service in full, out-of-
pocket, and if the patient requests that UW Health not disclose information about that
health care item or service to the patient’s health plan for purposes of payment or health
care operations, UW Health must grant the patient’s request with regard to that payor.
Such a restriction is limited to the specific encounter during which the health care item or
service was provided. To ensure that it complies with the restriction, UW Health will take
the following steps:
a. HIM will flag the restriction in the patient’s health/billing records.
b. HIM will notify Patient Business Services (PBS) when a request to restrict the
disclosure of PHI to the patient’s health plan for a health care item or service for
which UW Health has received payment in full, out-of-pocket has been made and
approved. This will allow PBS to implement the restriction in billing operations.
c. No claim for payment will be issued to the health plan for the health care item or
service and the restricted PHI will not be made available to the health plan for
payment or health care operations, except as may be required by law (e.g.,
d. The restriction will only apply to the individual health care item or service which
was paid for in full. Follow-up care that relates to the self-pay item or service,
but for which the patient does not also pay in full is not covered by the restriction
and may be disclosed to the patient’s health plan for payment purposes consistent
with UW Health’s minimum necessary policy.
e. If UW Health does not receive full payment for the health care item or service for
which the patient has requested the restriction, UW Health will make a
reasonable attempt to resolve payment issues with the patient before disclosing
any such PHI to the patient’s health plan. If, after making a reasonable attempt,
UW Health does not receive payment in full for the health care item or service,
UW Health may submit a claim for payment to the patient’s health plan.
5. Approval of a Request for Restriction for Non-Self-Pay Services-After consulting with
the Privacy Officer, as needed, HIM will inform the patient that the request has been
approved. HIM will also inform the patient that, regardless of the restriction, UW Health
may use and/or disclose the PHI: (1) as required by law, or (2) if the PHI is needed to
provide emergency treatment to the patient. If PHI is disclosed for purposes of providing
the patient with emergency treatment, UW Health will request that the health care
provider to whom the PHI was disclosed not further disclose the PHI. HIM may also
inform the patient of potential implications of the restriction. HIM will use the “Sample
Letter of Approval of Request for Restriction” unless approved by the HIM
a. HIM will scan the pertinent restriction paperwork into the patient’s medical
record as a release restriction and enter the release restriction FYI flag.
6. When UW Health agrees to a restriction, UW Health must comply with that restriction
during the term that the restriction is in place.
a. For restrictions related to cash pay items, UW Health may still use PHI for any
other reason permitted or required by law that is not inconsistent with the
restriction and may disclose PHI for any other reason required by law that is not
inconsistent with the restriction.
b. For any other type of restriction, UW Health may still use or disclose PHI for any
other reason permitted or required by law this is not inconsistent with the
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7. When a Request for Restriction is Denied
a. HIM will communicate the denial to the patient in writing. HIM will use the
“Sample Letter of Denial of Request for Restrictions.” HIM is not required to
provide a reason for denial, but may choose to do so.
b. If HIM believes it would grant a patient’s request for restriction if the patient
modifies the request, HIM may make reasonable efforts to assist the patient in
modifying the request for restriction in a manner that would result in approval of
8. Termination of Restrictions
a. UW Health may terminate a restriction if the patient submits a written request for
the termination of the restriction or if the patient agrees in writing to the
b. Except for a restriction related to a self-pay item or service (see Section IV (A)
(4)), UW Health may terminate a restriction if it informs the patient, in writing,
that it is terminating the restriction. Terminating a restriction is only effective
with respect to PHI created or received after UW Health informs the patient of its
decision to terminate the agreement to the restriction; UW Health must continue
to honor the restrictions with respect to PHI created or received during the period
when the restriction was in effect.
UW Health shall maintain written documentation of patient requests for restriction and associated actions
(approval, denial, or termination of a restriction) for a minimum of six years from the date of the action or
the date when the restriction was last in effect, whichever is later. If the documentation is maintained in
the patient’s health record, retention of the documentation will be based on the UW Health records
Patient Request to Restrict Use and/or Disclosure of Health Information
Sample Letter of Approval of Request for Restriction
Sample Letter of Denial of Request for Restrictions
45 C.F.R. § 160.103 – Definitions
45 C.F.R. § 164.501 – Definitions
45 C.F.R. § 164.502(b) – Minimum Necessary
45 C.F.R. § 164.512 – Uses and Disclosures for which Authorization is not Required
45 C.F.R. § 164.522(a)(1) – Right to Request Restriction
45 C.F.R. § 164.522(a)(2) – Terminating a Restriction
UW Policy 1.1 – Designation of the UW-Madison Health Care Component
UW Policy 1.2 – Designation of the University of Wisconsin Affiliated Covered Entity (UW ACE)
Sr. Management Sponsor: VP, Chief Information Officer
Author: Director, Health Information Management
Reviewer: UW Health Privacy Officer
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Approval Committee(s): Medical Records Committee; UW Health Administrative Policy and Procedure
UW Health Chief Administrative Officer
Next revision: 102019