You have the right to request restrictions on certain uses or disclosures of your health information. For example, you may request that your name not appear in the Hospital's Patient Directory while you are here as an inpatient. Requests for restrictions must be in writing. In most cases, we are not required to agree to your requested restriction. However, if we do agree, we will comply with your request unless the information is needed to provide you emergency treatment or comply with the law. If we do not accept your request, we will reply to you in writing with the reason. We are legally required to accept certain requests not to disclose health information to your health plan for payment or health care operations purposes as long as you have paid out-of-pocket and in full in advance of the particular service included in your request. If the service or item is part of a set of related services, and you wish to restrict disclosures for the set of services, then you must pay in full for the related services. It is important to make the request and pay before receiving the care so that we can work to fully accommodate your request. We will comply with your request unless otherwise required by law. Examples of restriction requests that the Hospital cannot honor include: Requests to restrict medical students or residents from accessing your health information. Requests restricting the Hospital from giving your name to an insurance company that will be asked to pay a portion of your bill. Requests restricting the Hospital from reporting your identity and condition to an agency or organization where the Hospital is required by law to do so.Restrictions may be requested at any time. To make a restrictions request, please print and complete a Request for Restrictions Form. You may either mail the form to the SHC Privacy Office, 300 Pasteur Drive - MC 5780, Stanford, CA 94395-5202 or fax it to 650-723-3628. Copies of the Request Form and assistance are also available at the Hospital's Release of Information Office at 450 Broadway, Room C14, Redwood City, CA 94063. Alternatively, you may request restrictions during the registration process at the Hospital.To terminate a restriction that the Hospital has accepted, send your request in writing to SHC Privacy Office, 300 Pasteur Drive - MC 5780, Stanford, CA 94395-5202 or fax it to 650-723-3628. Please include a copy of your original restrictions request or the date, patient name and medical record number that appeared on the accepted request.The Hospital may terminate a restriction that it had previously accepted, but must inform you in writing of the termination. In this situation, the termination only applies to your personal health information created or received after you have been notified of the termination.