Requesting a Restriction on the Disclosure of Your Medical Information to Your Health Plan
You have the right to request that University Hospitals not disclose certain medical information to your health plan and UH must grant your request if all of the following circumstances are true:
- Your restriction request involves the release of your medical information to your health plan for the purpose of obtaining payment or health care operations. This means you do not want UH to disclose your medical information to your insurance company to bill for a particular item(s) or service(s) or to permit a quality review or other similar activities;
- UH is not required by law to bill your health plan; and
- You, or someone on your behalf other than your health plan, pay in full prior to or at the time of service for the services or items that are the subject of your request.
You must request the restriction prior to or at the time of service for the particular service(s) for which you are requesting the restriction. For scheduled inpatient or outpatient procedures, you must make the restriction request at the time of scheduling, since insurance pre-authorization is often required.
You may obtain an estimate of the fees associated with the requested service(s), however the final line items and fees cannot be verified until the appointment(s) with your UH providers have been completed.
Downstream Providers: It is your responsibility to notify “downstream providers” of your restriction request. This means that you must request a restriction and pay out-of-pocket each time following the initial service. This can include follow-up care, therapy, and any other treatment after the initial service has been provided.
Bundled Payments: A bundled payment means that UH receives one fee for providing all aspects of treatment for a specific diagnosis or condition. This “lump sum” can cover routine drugs, x-rays, lab work and other items or services needed to treat the patient. If your restriction request involves an item or service that is part of a bundled payment, UH will provide you information about your options. For instance, if UH is not able to unbundle the item or service, we will discuss the option of paying out-of-pocket for the entire bundled service.
If you have questions about your right to request a restriction, you may contact:
UH Privacy Officer:
3605 Warrensville Center Road, Mail Stop #MSC 9105
Shaker Heights, OH 44122
You may also email your request to Compliance@UHhospitals.org.
Request a Restriction
To request a restriction on the disclosure of your medical information, please complete the amendment request form, which will be kept in your chart and sent to the UH Privacy Officer.