Protected Health Information Disclosure

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual's office instead of the individual's home.

I wish to be contacted in the following manner (check all that apply):

Home Telephone
O.K. to leave message with detailed informationLeave message with call-back number only

Written Communication
O.K. to mail to my home addressO.K. to mail to my work/office address0.K. to fax to this number

Work Telephone
O.K. to leave message with detailed informationLeave message with call-back number only

Other

Name:

Birthdate:

Date:

The Privacy Rule generally requires healthcare providers to take reasonable steps to limit the use or disclosure of, and requests for PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to uses or disclosures made pursuant to an authorization requested by the individual.

Note: Uses and disclosures for TPO may be permitted without prior consent in an emergency.