Here is an example from Section III - Rights of Patients, Allowing the patient to establish an alternative means of communication of protected health information, along with the sample form which may be used for that purpose:

ALTERNATIVE COMMUNICATION

OF PROTECTED HEALTH INFORMATION

 PURPOSE

To ensure the Patient's right to request that communications of Protected Health Information (APHI@) be delivered by alternative means or at alternate locations.

POLICY

A patient will be allowed to request that the Office communicate PHI to him by alternative means or at alternative locations. The Office shall accommodate reasonable requests.

PROCEDURE

1. The patient will be notified of the right to request communication by alternative means or at alternative locations in the Office's Notice of Privacy Practices.

2. The Office Privacy Official will manage requests to receive communications by alternative means.

3. When an inquiry is received from a patient regarding the right to request that the Office communicate with him or his personal representative by some alternate means, the Office will provide the patient with a copy of A Request for Communications by Alternative Means (ARequest for Communications@) form. A request will not be evaluated until this request form is completed and signed by the patient or personal representative. (See sample Request for Communications form following this Policy.)

4. The Privacy Official will review the completed Request for Communications form to determine if it is a reasonable request. The Office may not require an explanation for the request. The Office=s decision will not be based on the perceived merits of the request. The Office will accommodate a request determined to be reasonable.

5. The Privacy Official will complete the Response section of the Request for Communications form to inform the patient of the Office=s decision.

6. The Privacy Official shall maintain all requests and responses in the appropriate location in the patient=s Medical Record. (See the Policy ARetention of Protected Health Information.@)

 

 

 

 

SAMPLE

REQUEST FOR COMMUNICATION BY ALTERNATIVE MEANS/LOCATION

 

Patient Name: ____________________________    Medical Record Number _______________

Patient Address: ______________________________________________________________

I wish to receive communication of my Protected Health Information from the Office by the following mean:

_____________________________________________________________________________

_____________________________________________________________________________


 

_________________________________________              _____________________________
Signature of Patient or Personal Representative                              Date

 
 
______________________________________________________
Print Name

 
 
______________________________________________________
Personal Representative's Title (e.g., Guardian, Executor of Estate,
Health Care Power of Attorney)
 

                                                      RESPONSE TO REQUEST

Date Request Received: _______________________

Alternative communication has been:

_____ Accepted

_____ Declined: The request is not reasonable because:

_____________________________________________________________________________

_____________________________________________________________________________

 

 
_______________________________________      _________________________
Signature of Privacy Official                                          Date

 
 
__________________________________________           
Print Name

Distribution of copies: Original to patient=s Medical Record, copy to patient.