Restriction & Authorization Forms

The HIPAA Privacy Rule gives individuals the right to give authorization or request restrictions to Protected Health Information (PHI) by submitting the appropriate form below:

Restriction Request Form
Fill out this form to request that HealthLink restrict its use or disclosure of PHI. You may restrict what type of information is utilized and supplied to an organization as well as who can access your file and obtain PHI. Please return to the address listed at the end of the form.

Authorized Representative Form
Fill out this form to give specific entities or persons the right to use, disclose or receive PHI related to the services performed by HealthLink. Please return to the address listed at the end of the form.

Inquiries related to eligibility, benefits coverage, exclusions and payment must be directed to your health plan administrator and require that you obtain and complete a separate form.