Instructions request restrict 2026

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The document outlines the process for requesting a restriction on the disclosure of protected health information through form DHS 8028. It details the necessary information to be provided by the requestor, including their identity and legal authority if applicable, as well as the specific health information to be restricted. Additionally, it describes the responsibilities of MQD staff in verifying requests, documenting determinations, and communicating outcomes to requestors.

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Click ‘Get Form’ to open it in the editor.
Begin by documenting the name of the requestor in the designated field.
If you are a legal representative, describe your legal authority (e.g., lawyer, court order) and attach a copy of this authority to the form.
Clearly state the health information that you wish to restrict in the appropriate section.
Provide your mailing address in the specified field for correspondence.
Once completed, submit the form for verification by MQD staff, who will log and process your request accordingly.

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