/ SHARED SERVICES
Information Security and Privacy Office /

Request for Restriction and Use of Disclosures

For use by Department of Human Services (DHS) and Oregon Health Authority (OHA) clients asking to limit use and disclosure of their information.

Name (print): / ID number (case, prime, reservation numberor SSN):
Client’s mailing address:
Record holder (office, district): / Date of birth:
Location of record (address): / Date of request:

Submit this request to the office where services were received.

  • If you are asking to limit use and disclosure of your personal information, please consider that without your authorization, DHS or OHA may not be able to see if you qualify for services.

I am asking to limit the following information from being used and disclosed (be specific):

Full legal signature of individual or authorized personal representative:
/
Date:
Personal representative authentication:
/
Relationship to client:
DHS or OHA staff only: Approved Denied Delayed
If delayed we will act on your request by:
Reason for delay or denial:
(DHS or OHA representative signature) / (Date)

Your rights when requesting restriction of information:

  • You have a right to request restrictions on the uses and disclosures of your information.
  • You have a right to have an answer to your request within 60 days. If there are delays in getting you the answer, you will be notified in writing and this delay cannot be more than an additional 30 days.
  • If DHS or OHA agrees to your request, the restricted information will not be used or disclosed unless DHS or OHA ends the agreement.
  • Information in our record that was created or received while the restriction was in place will remain subject to the restriction.
  • Your request and the answer will be kept in your record.

You have a right to file a complaint if you disagree with the decision.

Complaints may be directed to any of the following:

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State of Oregon Department of Human Services

Governor’s Advocacy Office 500 Summer St. NE, E17 Salem, Oregon 97301-1097
Phone: 1-800-442-5238, Fax: 503-378-6532, Email:

Oregon Health Authority, Privacy Officer

500 Summer Street NE, E24, Salem, OR97301

Phone: 503-945-5780, Fax: 503-947-5396, Email:

U.S. Department of Health and Human Services, Office for Civil Rights
(for health information only)

Medical Privacy, Complaint Division, 200 Independence Avenue, SW HHH Building, Room 509H, Washington, D.C. 20201,
Phone: 866-627-7748, TTY: 886-788-4989, Email:

For current or former patients of the Oregon State Hospital (OSH) or BlueMountainRecoveryCenter (BMRC):

OSH – Director of Consumer and Family Services
2600 Center St. NE, Salem, OR97301
Phone: 503-945-7132 / BMRC – Superintendent
2600 Westgate, Pendleton, OR97801
Phone: 541-276-0810 Extension 236
This document can be provided upon request in alternative formats for individuals with disabilities or in a language other than English for people with limited English skills. To request this form in another format or language, contact your local office. For a list of local offices please see

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