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North Privacy Forms

Request to Restrict Protected Health Information

Use this form to add more privacy to your health information if you are facing immediate danger, identity theft or fraud, or you have a specific privacy concern. Submit the completed form to:

Health Net Federal Services, LLC
Privacy Compliance Office
2025 Aerojet Road
Rancho Cordova, CA 95742

Fax: 1-888-745-1545

Last Updated 10/15/2013