REQUEST for CONFIDENTIAL HANDLING
of PROTECTED HEALTH INFORMATION (PHI)
Please print all requested information to prevent delays & provide completed form to your facility
Maiden or Other Name
Address:___________________________________ City: ______________________ST: _______Zip:_________
Date of Birth:______-______-_____
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.
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
PARENT/LEGAL GUARDIAN/AUTHORIZED PERSON
RELATIONSHIP TO PATIENT
FOR INTERNAL USE ONLY
Complete the section below and retain with patient file.
Confidential Handling: Completed
If denied, reason for denial is:
We are unable to administer the request
Name of associate that processed request
Date Request was processed
Conf. GCHJF59EN 08/15