Patient Record of Disclosures

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

I wish to be contacted in the following manner (check all that apply):

Home Telephone
Cell Phone
- O.K. to leave message with detailed information
- Leave message with call back number only

Work Telephone
- O.K. to leave message with detailed information
- Leave message with call back number only

Written Communication
- O.K. to mail to my home address
- O.K. to mail to my work/office address
- O.K. to fax to this number

May release information to:

Other

Cabarrus Gastroenterology Associates
1070 Vinehaven Drive, NE
Concord, N.C. 28025 704-783-1840, FAX 704-783-1850

Privacy Rule generally requires healthcare providers to take reasonable steps to limit the use of 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.