Hipaa Request Authorization Form (Page 4 of 4) in pdf

Hipaa Request Authorization Form Page 4

TOPS MARKETS, LLC

[Insert Logo]

Request Communications by Alternate Means

I request that you communicate with me regarding my health matters as follows (Please describe your

requested communication methods and contact information. For example, you may request that we

contact you via e-mail only, or at your work address instead of your home address):

_____________________________________________________________________________________

NOTE: Tops will accommodate your reasonable requests. We may require further information before

implementing your request, but we will not ask you to explain the reason for your request.

_____________________________________________________________________________________

Disclosure of Immunization Records

I request and consent to the disclosure of the immunization records of:

Patient Name: _____________________

Patient Date of Birth: ______________

To the following school:

School Name: ______________________________

Address:

______________________________

Attention:

______________________________

If you are not the patient, please print your name and describe your relationship to the patient:

______________________________ __________________________________________

Print Name

Relationship to patient

Hipaa Request Authorization Form Page 4