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  • 621 Request Alternative Communication

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    edzuckerman
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    This document is a form for patients to request alternative communication channels with their healthcare provider. The form allows patients to specify preferred contact numbers and addresses for phone calls, postal mail, and emails. It also gives patients the option to refuse certain contact methods or provide limitations. Patients sign and date the form, and the healthcare provider's privacy officer also signs to accept or refuse the requested limitations with an option to provide reasons for refusal.

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    621 Request Alternative Communication.rtf

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    This document is a form for patients to request alternative communication channels with their healthcare provider. The form allows patients to specify preferred contact numbers and addresses for phone calls, postal mail, and emails. It also gives patients the option to refuse certain contact methods or provide limitations. Patients sign and date the form, and the healthcare provider's privacy officer also signs to accept or refuse the requested limitations with an option to provide reasons for refusal.

    Copyright:

    © All Rights Reserved
    Download as RTF, PDF, TXT or read online from Scribd
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    Download as rtf, pdf, or txt
    16 views2 pages

    621 Request Alternative Communication

    Uploaded by

    edzuckerman
    This document is a form for patients to request alternative communication channels with their healthcare provider. The form allows patients to specify preferred contact numbers and addresses for phone calls, postal mail, and emails. It also gives patients the option to refuse certain contact methods or provide limitations. Patients sign and date the form, and the healthcare provider's privacy officer also signs to accept or refuse the requested limitations with an option to provide reasons for refusal.

    Copyright:

    © All Rights Reserved
    Download as RTF, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as rtf, pdf, or txt
    of 2

    621

    Form to request alternative communication channels

    (On your letterhead)

    Request for other ways of communicating with me


    I do not need to provide any reason and simply request the following alternatives to or limitations on
    communicating with me by you or this practice:
    1.

    Please telephone me ONLY at this number(s): ______________________________

    When you call please follow these directions: __________________________________


    _______________________________________________________________________
    _______________________________________________________________________
    Please do NOT telephone me at this number(s): ________________________________
    _______________________________________________________________________

    2.

    Please direct all postal mail to this address: ________________________________

    _______________________________________________________________________
    Please do NOT send postal mail to this address: _______________________________

    3.

    You may e-mail to me at this address: ____________________________________

    ________________________________________________

    _______________

    Signature of client or his or her personal representative

    Date

    _________________________________________
    Printed name of client or personal representative

    ___________________________
    Relationship to the client

    ________________________________________________________________________
    Description of personal representatives authority

    Accepted
    Refused

    Reason(s): ______________________________________________________________
    _______________________________________________________________________
    _____________________________
    Printed name of Privacy Officer

    __________________________ ___________
    Signature

    Date

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