Sep Compliance/hipaa- 011a - Receipt Of Notice Of Privacy Practices Alternate Communication Request Form

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Receipt of Notice of Privacy Practices
ALTERNATE COMMUNICATION REQUEST FORM
Patient Name ________________________________________Date of Birth _____/_____/_______
(Print full name)
I wish to be contacted in the following manner (check all that apply):
 By home, cell or work phone listed in my registration as below.
Home – Cell - Work
Other ____________________________________
 O.K. to leave message on voice mail
____________________________________
 O.K. to leave message with individual
____________________________________
 Leave message with call-back number only ____________________________________
 Do not leave message
____________________________________
 Written Communication
 O.K. to mail to my home address
 O.K. to fax to this number ______________________
 O.K. to mail to my work/office address
 O.K. to e-mail to address listed in my registration
 O.K. to mail text me
I, ______________________________ give permission to the following individuals to obtain the indicated
(Name of Patient or Responsible Party)
information:
__________________________ whose relation to me is
_____ _ Phone (____)_____-________
(Name of person)
(Relationship to Patient)
__________________________ whose relation to me is
_ Phone (____)_____-________
(Name of person)
(Relationship to Patient)
__________________________ whose relation to me is
_Phone (____)_____-________
(Name of person)
(Relationship to Patient)
__________________________ whose relation to me is
_ Phone (____)_____-________
(Name of person)
(Relationship to Patient)
Prescription refills on my behalf
Test results on my behalf
Set up appointment/ or cancel on my behalf
Speak to the doctor/MA either in person or by telephone on my behalf
Pick up prescriptions, doctor’s orders, or other needs on my behalf with a photo ID.
Effective Date
Expires
Revoked
_____
Please note: This form does not apply to pregnancy, sexually transmitted diseases, contraception,
chemical dependency/substance abuse, or psychiatric/psychological conditions.
Initials
It is the responsibility of the patient to notify the physician’s office if there is a change in this information.
**Scan original in chart, copy may be given to patient**
By signing this waiver I release St. Elizabeth Physicians and its staff therein, from any liability for release of
information pertaining to my medical care as designated above and
I acknowledge that I have received a copy of
St. Elizabeth Physicians Notice of Privacy Practices. The effective date of the notice is:
09/23/13
.
Signature of patient or responsible person
________________________________________________
Relationship of Representative to Patient _________________________________ Date
Signature of witness __________________________________________________Date
Revised 2013.05.01
Form No.: SEP Compliance/HIPAA- 011A

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