kimdoanmd.com - HIPAA FORM

PATIENT RECORD OF DISCLOSURES
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.

The Privacy Rule generally requires healthcare providers to take reasonable steps to limit the use or disclosure of, and requests for PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to uses or disclosures made pursuant to an authorization requested by the individual.

Note: Uses and disclosures for TPO may be permitted without prior consent in an emergency
I wish to be contacted in the following manner (check all that apply):*

Home TelephoneMobile TelephoneWork TelephoneWritten CommunicationEmailOther
Home Phone #

Area CodePhone Number
Cell Phone #

Area CodePhone Number
Work Phone #

Area CodePhone Number
Email
example@example.com
If other, please list:
O.K. to leave message with detailed information Leave message with callback number only
O.K to mail my home address*

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If you would like us to contact someone other than the patient, please provide a name, phone number, and state the relationship with patient

Record of Disclosures of Protected Health Information

	Date	Disclosed to Whom (Address or Fax)	Is Authorized	Description/Purpose of Disclosure	By Whom Disclosed	Type Key	How Disclosure Was Made

Printed Name*
Date*

MonthDayYear
Date
Date Of Birth*

MonthDayYear
Date
Patient Signature*

Clear
If not signed by patient, please indicate:
Relationship

Parent or guardian of minor patientGuardian or conservator of incompetent patientBeneficiary or personal representative of deceased patient
Patient Name*

First NameLast Name
Should be Empty:

PATIENT RECORD OF DISCLOSURES