Patient Record of Disclosures

I would like to be contacted in the following manner (please check all that apply):

 

Home Telephone # (         )_________________

        □  It is o.k. to leave a message with detailed information.

        □   Leave a message with only a call back number.


 Cell Phone # (          )___________________

        □   It is o.k. to leave a message with detailed information.

        □   Leave a message with only a call back number.

 

Work Telephone # (          )__________________

        □   It is o.k. to leave a message with detailed information.

        □   Leave a message with only a call back number.

 

Written Communication

        □   It is o.k. to mail information to my home address.

        □   It is o.k. to mail information to my work/office address.

        □   It is o.k. to fax information to this number.

 

  □   Other ________________________________________________________________

 

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

 

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.

Healthcare entities must keep records of PHI disclosures. If completed properly, the information provided below will constitute an adequate record.

 

Record of Disclosure of Protected Health Information

DATE

Disclosed to Whom

Address or Fax #

Description and Purpose of Disclosure

By Whom Disclosed

(A)

(B)

(C)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(A) Check this box if disclosure is authorized   (B) TR-Treatment Records; PI- Payment Information; HCO- Healthcare Operations   (C) Disclosure was made by: F- Fax; P- Home Phone; C-Cell Phone; E-E-mail; M-Mail; O-Other

 

Patient/Guardian Signature: _________________________________________ Date:_________________

 

Port Orange Chiropractic, Inc.·3729 S Nova Rd. Port Orange, FL 32129·(386) 761-0520