Florida Department of Elder Affairs Request for Restriction on Use & Disclosure of Medical Informati

Form Template

Patients have the right to request that the Florida Department of Elder Affairs (DOEA) restrict the use and disclosure of patient medical records and information.

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The DOEA does not have to agree to patient requested restrictions. If the DOEA does agree to the requested restriction, they will abide by the restriction unless a medical emergency requires otherwise. Patients also have the right to request that the DOEA communicate certain medical information to the patient in confidence. The DOEA will accommodate reasonable requests through the Florida Department of Elder Affairs Request for Restriction on Use & Disclosure of Medical Information and or Confidential Communication app to receive communications of medical information by alternative means or at alternative locations only if patients (1) specify the alternative location, address, or telephone number and/or the alternative means of contact and (2) agree to be responsible for and explain how payment will be handled for any additional costs associated with the alternative method of communication. Check out the app for more information.

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