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REQUEST TO RESTRICT PROTECTED HEALTH INFORMATION (PHI) FORM Patients Name: DOH Facility: Date of Birth: / / Patients Address: Medical Record Number: Please specify the information to be restricted:

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How to fill out 691 request to restrict

How to fill out 691 request to restrict:

01

Start by obtaining a copy of Form 691, which is used to request a restriction on certain activities.

02

Fill in your personal information accurately, including your name, address, and contact details.

03

Specify the nature of the restriction you are requesting in detail. Clearly explain why you believe it is necessary and provide any supporting evidence or documentation.

04

Be sure to include any relevant dates or specific incidents that have led to your decision to request the restriction.

05

Indicate the duration for which you would like the restriction to be in place, if applicable.

06

Sign and date the form before submitting it to the appropriate authority or organization responsible for processing such requests.

Who needs 691 request to restrict:

01

Individuals who have experienced harassment, threats, or unwanted attention may need to fill out a 691 request to restrict.

02

If someone feels that their safety or well-being is at risk due to an individual or group's actions, they may find it necessary to request a restriction through this form.

03

This could apply to situations involving cyberbullying, stalking, or other forms of harassment that require legal intervention to ensure personal safety and privacy.

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