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Request to restrict disclosure DHS 8028doc - med-quest

Request to restrict disclosure DHS 8028doc - med-quest 2025

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The document is a request form from the State of Hawaii's Department of Human Services, specifically the Med-QUEST Division, for individuals to restrict the disclosure of their Protected Health Information. It includes sections for the applicant's details, mailing address, and signature, as well as a determination section for the Med-QUEST Division to indicate whether the request to restrict information will be granted or not.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your name in the designated field. Make sure to circle whether you are the Applicant, Recipient, or Legal Representative.
In the next section, provide a description of your authority if you are a legal representative. This clarifies your relationship to the applicant.
Specify the Protected Health Information you wish to restrict. Be as detailed as possible in this section to ensure clarity.
Fill in your mailing address, including city, state, and zip code, so that you can receive any correspondence regarding your request.
Sign and date the form at the bottom. Ensure that all information is accurate before submission.

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