Mr-4642 - Request For Specified Method Of Communication Form printable pdf download

Oregon Health & Science University

Hospitals and Clinics

ACCOUNT NO.

REQUEST FOR SPECIFIED

MED. REC. NO.

METHOD OF COMMUNICATION

NAME

BIRTHDATE

Page 1 of 1

Stamp Patient Card Here

SECTION A: Individual to complete the following information. (Please print)

NAME ____________________________________________________________________________________

Last

First

Middle

ADDRESS _________________________________________________________________________________

TELEPHONE NO. ___________________________

BIRTH DATE __________________________________

MEDICAL RECORD NO. _____________________

REQUEST:

I hereby request that communications containing my health information from

__________________________________________________________________________________________

(Please specify OHSU service area and/or department)

be communicated in the following manner:

At a telephone number other than my home number.

Preferred telephone number is: __________________________________________________________

At a mailing address other than my home mailing address. Preferred mailing address is: _____________

____________________________________________________________________________________

Via email. My email address is: __________________________________________________________

(If email is selected, the individual will need to have an OHSU email communication agreement on file.)

Other. Please specify: _________________________________________________________________

If the specified method of communication is accepted, this method of communication will expire 180 days from the

date of signing or shall remain in effect for the period listed below:

Expiration date/event: ______________________

I understand that OHSU can only accommodate reasonable requests and may condition its accommodation upon

the following:

a. information from me as to how payment of the costs of the accommodation will be handled; and

b. the specification of an alternative address or other method of contact.

I understand that this request is for an alternative manner or method of receiving communications from the

service area(s) or department(s) specified above. I also understand that this request does not include

communications from other service areas and departments of OHSU.

Date: ___________________

Signature of Patient or Legal Representative ____________________________________________________

Printed Name of Legal Representative (If applicable) _____________________________________________

SECTION B: OHSU to complete the following.

The above request to provide communications to the individual via an alternative manner and method has been

reviewed and has been:

MR1449

Accepted

Denied (OHSU cannot reasonably accommodate request)

Comments: ________________________________________________________________________________

Signature of Staff Member ___________________________________________________________________

Print Name and Title ________________________________________________________________________

Department / Area __________________________________________________________________________

MR-4642

ONLINE 3/2003

Mr-4642 - Request For Specified Method Of Communication Form

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