Alternate Communications Request Form
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1Pt. Name:______________________________________________
Address:_______________________________________________
______________________________________________________
City
State
Zip
MRN: _________________________________________________
DOB: _________________________________________________
Alternate Communications
SEX:______
Request Form
DOS: _________________________________________________
Request for Alternate Communications Regarding Medical Information
Date:
Month / Date / Year
I wish to request that UT Southwestern Medical Center communicate with me about all medical and billing matters in the following manner:
I am aware this request will apply to all UT Southwestern Medical Center Ambulatory Services until modified: (Fill in the circle to all that apply)
Leave the above listed messages at the following alternate telephone number (
)
All medical and billing correspondence from Southwestern Medical Center should be sent to the following alternate address:
Street:
P.O. Box:
City:
State:
Zip:
For other requests, please contact the UT Southwestern Privacy Officer at 214-648-6080.
We will accommodate all reasonable requests. The determination of reasonableness may be based solely on the administrative difficulty
of complying with the request.
If you cannot be reached at the designated alternate location or contact number you specify, Southwestern Medical Center or our
designated billing agent may use any other means to contact you for payment.
Signature of Patient/Responsible Party (Relationship to Patient)
Time
Date
Printed Name of Patient
Time
Date
Signature of Witness
Address / City / State / Zip Code
Time
Date
Printed Name of Witness
FOR OFFICE USE ONLY:
Above Information Changed
d
EPIC
Date
By
Staff Signature
Page 1 of 1
Form # AMA/ACRF-001 / 02.04
(Rev. 03.26.13)
Original - Health Information Management Department
Copy - Privacy Officer
(Reviewed 09/13)
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Parent category: Medical