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.

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.