It is the policy of Purdue University to permit an individual or their representative to request a restriction of the use and disclosure of their protected health information and for the request to be promptly reviewed.

Purdue University is not required to agree to the restriction. If however, the Director, HIPAA Privacy Compliance does agree, Purdue may not use or disclose the protected health information in violation of the restriction, except, if the individual who requested the restriction is in need of emergency treatment and the restricted information is needed to provide the emergency treatment, Purdue may use the restricted information or may disclose the information to a health care provider to provide treatment to the individual and must request that the health care provider not further use or disclose the information. Any restriction agreed to by Purdue is not effective to prevent uses or disclosures permitted or required in the HIPAA Privacy Rule, §§164.502(a)(2)(ii), disclosures to the Secretary of HHS; 164.510(a), facility directory information; or 164.512, disclosures required by law.

Request of Privacy Protection of Protected Health Information - Policy and Procedure (pdf)

Request of Privacy Protection of Protected Health Information - Form (pdf)
Request of Privacy Protection of Protected Health Information - Form (doc)