CCHC Medical Privacy Declaration Form

For Healthcare Services & Information


Fill in name of institution/person (Physician/Health care practitioner/Health plan/Hospital/Clinic/School/Pharmacy/Other)

I reject the government’s claim that citizens have a public responsibility to disclose private and personal medical information as stated in the medical privacy recommendations written by the U.S. Department of Health and Human Services (9/11/97).

I also find the federally permitted use and disclosure of personal, medical and health data by various institutions, corporations, and individuals under the Health Insurance Portability and Accountability Act (Public Law 104-191-August 21 1996) and the subsequent federal medical privacy rule (Standards for Privacy of Individually Identifiable Health Information, 45 CFR Parts 160 and 164) to be detrimental to medical privacy and the confidentiality of medical records and individually-identifiable health data. The federal medical privacy rule took effective April 14, 2001 with implementation and enforcement set for April 14, 2003. Only stricter state medical privacy laws can supersede the requirements of the federal rule.

For the record, I therefore and hereby declare my express wish and intent for the truly confidential treatment of medical records, health information, psychological testing, genetic testing, and all other information received, heard, said, written, or stored in the course of interactions with the above named person/corporation/agency. Please keep this form on file. To be specific, without written, specific, informed and voluntary consent, I ask you (the above) not to disclose, sell, or otherwise release, to the following agencies/groups or for the following purposes (as checked below), the personal, medical, psychological, financial, genetic, demographic, or health data, or body parts and tissues of ________________________________________ (Name of self, child, or guardian responsibility).

 Payment and Treatment
 Health care operations
 Hospital and facility patient directories
 Public safety
 Environmental Protection Agency
 Central Intelligence Agency
 National Transportation Safety Board
 Food and Drug Administration
 Occupational Safety & Health Admin.
 State departments of health
 Medical or other review boards
 Federal Bureau of Investigation
 Departments of agriculture
 Mine Safety and Health Administration
 Government oversight agencies
 Community agencies/groups
 Government welfare departments
 Government education agencies
 Government human services departments
 Government contractors
 Any government agency/department
 Foreign governments/organizations.
 Newborn metabolic testing data collection
 Birth defect registries/data collection
 Immunization registries/data collection
 Cancer registries/data collection
 Public health surveillance
 Workforce/Injury data collection
 Indian health registries
 Minority, race, or health disparities databases
 Newborn hearing screening database
 Genetic testing/DNA databases
 Medical error reporting systems
 Private registries/data collections
 Health status databases
 OASIS - home health database/collection
 Computerized smart cards
 Disease-specific organizations
 Centers for Disease Control & Prevention
 U.S. Dept. of Health and Human Services
 Pharmaceutical benefit management co.
 Disease management companies
 Tissue or organ donation organizations
 Public health agencies/officials
 Any government database/data collection
 Law enforcement officers/agencies
 Public policy researchers
 National security
 Medical/Scientific researchers
 Peer review organizations
 Certification processes
 Marketing of services or products
 Accreditation and licensing
 Clinical guideline development
 Training programs
 Social service agencies
 Pharmaceutical companies
 Judges/Administrative law staff
 Members of the clergy
 Coroners/Medical examiners
 State fire marshals
 Health boards
 State or other ombudsman
 Workman’s Compensation
 Banks/credit card payments
 Media/Press/News Services

This restriction on data disclosure, use and access shall be valid until otherwise removed by written authorization of the subject (or parent or guardian of subject if subject is a minor or under guardianship) of the information.


Relationship to Above Person


Printed Full Name


City / State

Zip code

CCHC DISCLAIMER: CCHC is a non-profit 501(c)3 organization. CCHC provides this form only as information to assist individuals in restricting access to or use of their individually identifiable medical or financial information. CCHC specifically does not warrant the effectiveness of said form in restricting access to or use of personal information by government agencies or private organizations. CCHC is not liable for any injury, either in whole or in part, caused, directly or indirectly, by use of this form. With the advice to the user that under the law this form may not be binding, it does however express your desire for medical, financial and personal privacy. It also expresses your protest if your medical records and other personal information are accessed, used or disclosed without your written, informed and voluntary consent.

Form created and distributed for CCHC's:
"For the Record" Medical Privacy Project
Citizens' Council on Health Care
1954 University Ave. W., Suite 8
St. Paul, MN 55104, 651-646-8935,

Copyright © Citizens' Council on Health Care 2001