Form #5 - REQUEST FOR RESTRICTION ON THE MANNER OF CONFIDENTIAL COMMUNICATION : Torrance Memorial Medical Center

REQUEST FOR RESTRICTION ON THE MANNER OF CONFIDENTIAL COMMUNICATION - Form #5

You may request to receive confidential communications of Protected Health Information (PHI) by alternative means or at alternative addresses. For example, you may not want your appointment notices or your bill to go to your home where a family member might see it.

We may not ask you the reason for your request. We will accommodate all reasonable requests. If you make a special request, you must give us an alternative address or other method of contacting you (phone number, email address, etc.). This restriction is FOR THIS VISIT ONLY and will automatically terminate when you are discharged from the hospital, after your outpatient visit or after your course of care is finished.

Please specify how or where you wish to be contacted:

Do not send any mailing (including my bill) to my home address. Use this address instead:
(Office use guarantor field)

Alternative Address:

City, State, Zip:

Do not call my home phone number. Use this phone number instead:
(Office use guarantor field)

Alternative Phone Number:

Signature of Patient or Representative:
Print Patient Name or Representative:
If Representative, give relationship:	Date:

Torrance Memorial Medical Center Acceptance of Restriction

Torrance Memorial Medical Center Respresenative Signature:

Date:

REQUEST FOR SPECIAL RESTRICTION ON THE Manner of Confidential Communication
HIPAA FORM #5 Page 1 of 1

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