Request For Restriction

By completing this form below, I understand that Mosaic Life Care does not have to agree to a restriction. I understand that if Mosaic Life Care agrees to a restriction, Mosaic Life Care may still use and disclose my information for:

  • Emergency treatment
  • When I request to access my information
  • When I request an accounting of disclosures
  • For facility directories
  • For uses/disclosures for which consent, authorization or an opportunity to agree or object is not required.

Patient Name:

Street Address:

City:

State:

Zip:

Date of Birth:

Phone:

I am requesting that you restrict the uses and disclosures of the following information:

Patient or Personal Representative Name:

Today's Date:

If you are the personal representative, please include your relationship to the patient: