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STATE OF HAWAII Department of Human Services Request Division Request to Restrict Disclosure of Protected Health Information I, (if legal Print name of Circle One: (Applicant, Recipient, Legal Representative)

How to fill out request to restrict disclosure

How to fill out a request to restrict disclosure:

1. Begin by writing your contact information at the top of the request form. Include your full name, address, phone number, and email address.
2. Next, address the request to the appropriate authority or department. This could be a government agency, a company, or any other organization that is involved in the disclosure of your personal information.
3. Clearly state that you are requesting to restrict the disclosure of your personal information. Be specific about what information you want to be kept confidential, such as your address, phone number, social security number, or any other sensitive data.
4. Provide a brief explanation of the reasons behind your request. For example, you may be concerned about identity theft, harassment, or any other potential risks associated with the disclosure of your personal information.
5. Include any relevant supporting documents or evidence to strengthen your request. This could be copies of police reports, court orders, or any other documentation that supports your claim for restricting the disclosure.
6. Sign and date the request form to make it legally binding and valid. It's important to ensure that your signature matches the one on file for official identification purposes.
7. Make a copy of the completed request form for your records before sending it to the appropriate authority. You may choose to send it via certified mail or any other secure method to ensure delivery and to have proof of submission.

Who needs a request to restrict disclosure:

1. Individuals who are concerned about the privacy and security of their personal information.
2. Victims of identity theft, harassment, or any other form of abuse that involves the disclosure of personal information.
3. People who want to safeguard sensitive data from being shared with unauthorized parties or entities.

Remember, it's important to follow any specific guidelines or requirements provided by the authority or department you are submitting the request to.

For pdfFiller’s FAQs

What is request to restrict disclosure?

A request to restrict disclosure is a formal submission made to prevent certain information from being disclosed to the public.

Who is required to file request to restrict disclosure?

Any individual or entity who wishes to protect sensitive or confidential information from being made public.

How to fill out request to restrict disclosure?

The request must be filled out completely, including a detailed explanation of the information to be restricted and the reasons for it.

What is the purpose of request to restrict disclosure?

The purpose is to safeguard sensitive information from being disclosed to the public, which could potentially harm individuals or entities.

What information must be reported on request to restrict disclosure?

The request must include specific details about the information to be restricted, the reasons for the restriction, and any supporting evidence.

How can I modify request to restrict disclosure without leaving Google Drive?

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The pdfFiller mobile app makes it simple to design and fill out legal paperwork. Complete and sign request to restrict disclosure and other papers using the app. Visit pdfFiller's website to learn more about the PDF editor's features.

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Make sure you get and install the pdfFiller iOS app. Next, open the app and log in or set up an account to use all of the solution's editing tools. If you want to open your request to restrict disclosure, you can upload it from your device or cloud storage, or you can type the document's URL into the box on the right. After you fill in all of the required fields in the document and eSign it, if that is required, you can save or share it with other people.