Home Health Agency


Government Agency (State Health Dept., U.S. Dept. of Health and Human Services) - use only if already collected (see below)

I find the federally-required collection of personal, financial, and medical data to be detrimental to medical privacy, personal privacy, financial privacy, and the confidentiality of medical records and individually-identifiable health,financial, and personal data. Section 1395bb of the Social Security Act (42 U.S.C. 1395bbb) and the subsequent 1999 federal regulation (42 CFR Part 484, Medicare and Medicaid Programs: Comprehensive Assessment and Use of the OASIS as Part of the Conditions of Participation for Home Health Agencies, January 25, 1999; as amended June 18, 1999) became effective August 19, 1999 and has allowed the collection and transmission of patient and family data to state departments of health and the U.S. Department of Health and Human Services without the consent of patients or family members.

For the record, I therefore and hereby declare my express wish and intent to prevent disclosure or transmission of medical, personal, health, psychological and financial information to State or Federal government agencies, or the Outcome and ASsessment Information System. Please keep this form on file. To be specific, without written, specific, informed and voluntary consent, information in the list below labeled “Collection Categories” or any other information on ________________________________________ (Name of self or guardian responsibility) shall not be collected or disclosed for the OASIS system.

Collection Categories:

  • behavior
  • educational level
  • medications
  • sensory status
  • transportation options
  • use of the emergency room
  • medical diagnoses
  • relationships
  • race/ethnic background
  • ability to breath
  • hospitalizations
  • psychological status
  • emotional stability
  • living arrangements
  • type of insurance
  • ability to urinate/defecate
  • use of nursing home
  • financial status (not yet disclosed)
  • medical conditions
  • housing
  • treatments received
  • integrity of skin
  • neurological status
  • functional status
  • safety hazards
  • ability to speak
  • ability to eat/walk
  • prognosis

FOR STATE OR FEDERAL AGENCIES (as named above): If any data for OASIS has already been collected and transmitted to State or Federal government agencies on ________________________________________ (Name of self or guardian responsibility), I hereby declare my express wish and intent that the data held by HHS or other government agencies/contractors be deleted and destroyed, and that entities in the seven ‘routine use’ categories either not receive the data or, if they have received it, be required to destroy and delete the data as well. These include, but are not limited to:

  • The Department of Justice, court or adjudicatory body with an interest in litigation
  • Agency contractors or consultants hired for services related to the OASIS system of records
  • Federal and state oversight agencies for assessment of cost, effectiveness, and quality of care
  • Federal and state Medicare and Medicaid agencies
  • Peer Review Organization to assess quality of care of individual providers and health care facilities
  • Individuals or organizations for research related to prevention of disease or disability, restoration or maintenance of health, or payment-related projects
  • A member of Congress or a Congressional staff member in response to an inquiry made at the written request of the constituent about whom the record is maintained. (Federal Register, June 18, 1999)

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
161 St. Anthony Avenue, Ste 923
St. Paul, MN 55103, 651-646-8935
Website: www.cchfreedom.org

Copyright © Citizens' Council on Health Care 2001