Request_alternative_communications

Name

First Name Last Name
Date of birth

MonthDay Year
Date
Date of request

MonthDay Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
As allowed by the Privacy Regulations, I wish for this office to provide the following “Alternative” means of communicating my Protected Health Information:
Mailing Address

Type option 1
If appropriate, please contact me at the following Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone.

Type option 1
Phone Number
Please enter a valid phone number.
Fax

Type option 1
Fax number
Please enter a valid phone number.
Email
example@example.com
Email

Type option 1
I have the following additional requests for confidential communications regarding my Protected Health Information:

Type option 1
Please Explain:
I understand that there may be additional costs associated with this request and I agree to reimburse this office for such costs.
Signature

Clear
Date

MonthDay Year
Date
Accepted as requested

Type option 1
Modified as noted:

Type option 1
Modification:
Authorized signature of facility

Clear
Date

MonthDay Year
Date
Should be Empty: