FOX VALLEY FAMILY PHYSICIANS

Request to Receive Confidential Communications of Protected Health Information
As stated in our Notice of Privacy Practices, you may request that we communicate confidential health information to you by alternative means or in alternative locations. The Privacy Rule requires us to accommodate requests if reasonable.

Please assist our staff by designating how you prefer to be contacted
Home phone:
   
Cell phone:
   
Work phone::
ext.

Appointment confirmations
 Our receptionists will be calling your HOME with appointment reminders.
  Yes  
  No   Leave message on my home answering machine
  Yes  
  No   Leave message with persons at my home

All other health information
The physicians and nursing staff often need to speak with you regarding medical issues.
If unavailable, please authorize ONE location where we may leave a message:
  Home answering machine
  Cell phone voice mail
  Work voice mail
For the message left, please authorize the type of information you would like left:
  All pertinent information
  Leave only a request to call back, referencing the office phone number.
Persons at the home number you authorize us to leave a message with:
Please indicate their names: (i.e. your spouse: Sally or James Smith, your parent(s): John & Jane Smith)
  Yes  
  No   Send sealed confidential information to my home address
  Yes  
  No   Send sealed confidential information to another address:
               
               
               
Patient (if >18 years old) or Parent Signature                          Date