Alden, NY · Erie County
Request to Restrict Use or Disclosure of Protected Health Information
This form lets patients ask Erie County to restrict use or disclosure of their protected health information and is submitted to the Erie County Chief Privacy Officer.
- licensed online notary
- ~15 min average
- Notarized PDF emailed
What you’ll need
- Government-issued photo ID
- Webcam-enabled device (laptop or phone)
- This form, ready to upload as a PDF
What this form is
This two-page form lets a patient ask Erie County to restrict use or disclosure of specified protected health information, identify departments and people involved, and provide contact details. Erie County says notarization is required when the request is submitted by mail; in-person requests use the verification methods listed on the form. An authorized representative must include a copy of the document establishing their authority.
Who needs it
Patients asking Erie County to restrict use or disclosure of their protected health information, or authorized representatives making that request, use this form.
Why it needs a notary
The form includes an acknowledgment block, not a jurat; the patient or authorized representative must personally appear before a notary and acknowledge signing the form.
How to get this notarized
- 1
Download the Form
Get the Request to Restrict the Use or Disclosure of Protected Health Information form.
- 2
Complete the Request
Add patient contact details, the departments and information involved, and any people Erie County should not disclose information to.
- 3
Book an Online Notary
If submitting by mail, arrange a video appointment with a commissioned online notary.
- 4
Sign on Video
Show identification and acknowledge your signature before the notary during the video session.
- 5
Submit to Erie County
Send the completed request to the Erie County Chief Privacy Officer using the address or email listed on the form.
Preview the form
The blank PDF straight from Alden. Look it over, then upload your filled copy to start the notary session.
You’ll need ID and a webcam.
A licensed online notary will join you on video, verify your government-issued ID, witness your signature, and apply their seal. You’ll receive the notarized PDF by email when the session ends.
Frequently asked questions
- How do I submit this request?
- Complete the form and return it to the Erie County Chief Privacy Officer at the mailing address or email shown on the form. If submitting by mail, notarization is required.
- Do I need to have the form notarized?
- Erie County requires notarization for requests submitted by mail. For an in-person request, the form lists verification options using photo identification and, for an authorized representative, supporting documents.
- Can I sign this request with an online notary?
- New York has authorized remote online notarization for its notaries under Executive Law §135-c since 2023. You can sign during a video session with a commissioned online notary; confirm with the city, town or village if unsure.
- What should an authorized representative include?
- The form asks the representative to provide their name and address, identify their authority, and submit a copy of the document establishing that authority.