Request For Confidential Handling Of Protected Health Information (Phi) Form printable pdf download

Request For Confidential Handling Of Protected Health Information (Phi) Form

REQUEST for CONFIDENTIAL HANDLING

of PROTECTED HEALTH INFORMATION (PHI)

Please print all requested information to prevent delays & provide completed form to your facility

Patient Name:________________________________________________________________________________________

Last

First

Maiden or Other Name

Address:___________________________________ City: ______________________ST: _______Zip:_________

Date of Birth:______-______-_____

Phone #:________________________________

I request confidential handling of communications to me regarding my PHI:

 For all health information

 Only for health information related to a particular illness or injury________________________________________

 For a specified time period: From ______________________________ t o ________________________________

 For billing matters only.

Communication of PHI to me should be handled in the following way:

 Mail to an alternative address of: __________________________________________________________________

Via Email only:__________________________________

*For security of your records, all emails are ro u ti n e ly sent encrypted.

encrypted email disclaimer:

I understand that records sent through unencrypted email poses a security risk but it is my requested

method of receipt.

(Please initial)

To an alternative telephone number:

__________________________________________________

 Other (please specify):___________________________________________________________________________

I understand that you have the right to deny my request if it would be difficult to administer. I agree that if this request

impacts how payment is made for health care services provided to me, I will guarantee payment of these services by

paying in full at the time of the request.

SIGNATURE OF PATIENT

DATE

PARENT/LEGAL GUARDIAN/AUTHORIZED PERSON

DATE

RELATIONSHIP TO PATIENT

FOR INTERNAL USE ONLY

Complete the section below and retain with patient file.

Decision

Confidential Handling:  Completed

 Denied

If denied, reason for denial is:

 We are unable to administer the request

 Other_________________________________________________

_________________________________________

_________________________________

Name of associate that processed request

Date Request was processed

Conf. GCHJF59EN 08/15

Request For Confidential Handling Of Protected Health Information (Phi) Form

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