Patient’s Request to Receive Confidential Communications by Alternative Means

Name

First Last

Patient ID#:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Work Phone

As provided by Privacy Rule Section 164.522(b), I hereby request that ADVANCED FAMILY EYECARE, LLC (the “Practice”) make all communications to me by the alternative means that I have listed below.

Alternative Phone Number

Alternative Mailing Address

Other

Mark all written communication to me as follows:

CONFIDENTIAL PROTECTED HEALTH INFORMATION

Other

I understand and acknowledge that:

This authorization is voluntary and I may refuse to agree to its terms without affecting any of my rights to receive healthcare at the Practice.
This Authorization may be revoked at any time by notifying the Practice in writing at the above address to the attention “Privacy Officer.”
The revocation of this authorization will not have any effect on disclosures occurring prior to the execution of any revocation.
I may see and copy the information described in this form, if I ask for it, and I will get a copy of this form after I sign it.
This form was completely filled in before I signed it and I acknowledge that all of my questions were answered to my satisfaction, that I fully understand this authorization form, and have received an executed copy.
This authorization is valid as of the date I have signed below and shall remain valid until revoked or changed.

Name of Individual (Printed)

First Last

Signature

Date

Witness:

Advanced Family Eyecare, LLC – Dr. Simki Shah, OD

Patient’s Request to Receive Confidential Communications by Alternative Means

Patient’s Request to Receive Confidential Communications by Alternative Means

Mark all written communication to me as follows:

Advanced Family Eyecare