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My Omni Housecalls, will abide by HIPPA Privacy Rule. As Individuals, you have the right to request a restriction on uses and disclosures of your protected health information. Within keeping the HIPPA guidelines, we ask that you name individuals that My Omni Housecalls may speak with regarding your medical care. This will allow My Omni Housecalls the ability to make an informed decision as to whom we will release information to.

Please list below the names of individuals to whom we may speak with and who we need to restrict such information:

I understand that my information will only be shared with my permission. I understand that this release expires with receipt of a newly signed document.