 Chart Number _____________________ |
| Request for Confidential Communication |
I, _______________________ (patient name), hereby request Urology Specialists to keep communications regarding my protected health information confidential. To accomplilsh this request, please adhere to the following: ( ) You can contact me by phone at the following numbers:
Home: (_____)____________________
( ) You can leave messages on my answering machine/voice mail as follows: Work: (_____)_____________________ Cell: (_____)______________________
Home: YES ____ NO ____
( ) You can leave messages with, and release verbal information to: Work: YES ____ NO ____ Cell: YES ____ NO ____ YES ______ NO ______ If yes, please state Name: _________________________________ Relationship: ______________________ Name: _________________________________ Relationship: ______________________ Signed ___________________________________ Date: ___________________ If you are not the patient, please specify your relationship to the patient ________________________________ |
