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STATE OF CALIFORNIAHEALTH AND HUMAN SERVICES AGENCYCALIFORNIA DEPARTMENT OF PUBLIC HEALTH PRIVACY OFFICECONFIDENTIAL REQUEST TO RESTRICT USE AND DISCLOSURE OF PERSONAL INFORMATION APPARENT, GUARDIAN

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How to fill out request to restrict use

01

Start by stating your name and contact information.

02

Provide the name and contact information of the person or organization who you are requesting to restrict use from.

03

Clearly state the reason for your request to restrict use.

04

Include any supporting evidence or documentation that can help strengthen your request.

05

Specify the specific actions or restrictions you are requesting, such as cease and desist, removal of content, or limited access.

06

Mention any relevant legal or contractual agreements that may support your request.

07

Clearly communicate your expectations and the consequences of non-compliance.

08

Sign and date the request.

09

Deliver the request through a reliable method, such as certified mail or email with read receipt.

10

Keep a copy of the request and any responses for your records.

Who needs request to restrict use?

01

Anyone who believes their rights are being violated or their intellectual property is being misused may need to file a request to restrict use. This includes individuals, businesses, organizations, or legal entities.

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