DISCLOSURE RESTRICTION REQUEST FORM
This mobile app is to be used to file an official request for restriction of protected health information disclosure.
5,000 Companies save time and money with GoCanvas
It includes information like name, ss#, date of birth, address, city, state, zip and phone. It is then to be signed by the patient or student athlete.
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“I’m not a tech guy and I was able to pick this thing up in probably an hour, and actually start to build apps. I’ve done them over lunch when I’ve gotten frustrated with a process that didn’t exist in our company. So for non tech people who’ve got a problem, the support here is awesome and I’d recommend it to anybody, not just in our industry.”