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.

YesNo         Home or cellular telephone
YesNo         OK to leave message with the detailed information
YesNo         Leave message with call-back number only
YesNo         Work telephone
YesNo        OK to leave message with detailed information
YesNo         Written Communication
YesNo         OK to mail to my home address
YesNo         OK to email. Email Address:
YesNo         OK to text. Cell #:
YesNo         OK to mail to my work/office address
YesNo         OK to (enter here)

YesNo         Spouse Name
YesNo         Parent Name
YesNo         Child Name
YesNo         Other (Specify):
YesNo         None

* By checking this box and entering my name below, I agree that the information above is accurate and expresses my wishes for the use and disclosure of my protected health information.

Patient Name:

(*You must agree to submit this form)