Request for Restriction of Minor’s Reproductive Health Information

Hawaii state law (HRS 577A) provides minors age 14 through 17 years old the right to restrict information about their reproductive health treatment and services from being disclosed to the minor’s parents/guardian.

The law also provides that health professionals involved in treatment may assist minors in completing and submitting a request for non-disclosure to a health plan.

Please use this form to submit a request for non-disclosure of reproductive health treatment or services on behalf of a minor patient.

Request for Restriction of Minor’s Reproductive Health Information Form [PDF]

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