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Broadway Medical Clinic, LLP REQUEST FOR RESTRICTION ON USE/DISCLOSURE OF MEDICAL INFORMATION AND/OR CONFIDENTIAL COMMUNICATION Patient Name: Phone Number: (() (Day)) (Evening) Patient Address: (Street

How to fill out request for restriction on

How to fill out request for restriction on:

1. Begin by stating your full name, contact information, and the date of the request.
2. Clearly state the reason for requesting the restriction on certain activities or information.
3. Specify the duration or timeframe for which you are seeking the restriction. This can be a specific date or an ongoing request.
4. Provide any supporting documents or evidence that may strengthen your case for the restriction.
5. Clearly outline the activities or information that you are requesting to be restricted. Be specific in describing what you want to be restricted and why.
6. State any potential consequences or harm that could occur if the request for restriction is not granted.
7. Finally, sign and date the request for restriction, and include any additional contact information if necessary.

Who needs request for restriction on:

1. Individuals who have concerns about their personal information being shared or accessed by others without their consent may need to request a restriction on certain activities.
2. Businesses or organizations that have sensitive information or trade secrets may also need to request restrictions to protect their assets.
3. In some cases, individuals who have experienced harassment or threats may request a restriction on certain individuals or places to ensure their safety and privacy.

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