In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their Protected Health Information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual’s office instead of the individual’s home.
I wish to be contacted in the following manner (check all that apply):
- Home Phone
- OK to leave message with detailed information OR
- Leave message with call-back number only
- Cell Phone
- OK to leave message with detailed information OR
- Leave message with call-back number only
- Work Phone
- OK to leave message with detailed information OR
- Leave message with call-back number only
- Online Communication via Patient Web Portal
- OK to send me messages on the website regarding my care
(I have read the Online Informed Consent)
- Written Communication
- K. to mail to my home to my home address
- K. to mail to my work/office address
- K. to fax to this number _______________
- Permission to discuss Protected Health Information with the following:
- Names _____________________ Phone numbers: ________________
Of all the above contact methods of communication, please indicate which method (s) is/are best for you to be contacted regarding appointment reminders, lab results and other communication.