Privacy Compliance Policy

REQUEST TO RESTRICT MANNER AND METHOD

OF CONFIDENTIAL COMMUNICATION

SECTION A: Client to complete the following information.

DATE: ______________________

Client NAME: _______________________________ BIRTH DATE: ______________

Client ADDRESS:

_______________________________________________________________________

Client TELEPHONE NO.:_____________________ REC. NO.:_________________

REQUEST

I hereby request to receive confidential communications from HDC regarding my health condition, care, treatment, services, and/or payment in the following alternative manner and method (check all that apply):

  At a telephone number other than my home number. Telephone number is:

____________________.

  At a mailing address other than my home mailing address. Mailing address is:

___________________________________________________________________ 
_________________________________________________________________Vi a e-mail. My e-mail address is:

______________________________________________________.

  Other. Please specify:

_______________________________________________________________.

In the event the Client requests, email communication, please complete the Email Consent form.

I understand that, if HDC agrees to provide me with confidential communications regarding my health care via the above-identified alternative manner and method, HDC may condition his/her agreement upon the specification of an alternative address or other method of contact.

Client signature                                                                    25

___________________________________________________________________________

SECTION B: HDC to complete the following.

The above request to provide confidential communications to the Client via alternative manner and method has been reviewed by HDC and has been:

  Accepted         Denied (HDC cannot reasonably accommodate request)

Comments:

___________________________________________________________________________ 
__________________________________________________________________

 Signature ______________________________________ Date _____________________

If HDC has agreed to the above request, Client will receive a copy of this signed agreement.

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