UAMS ADMINISTRATIVE GUIDE
REVISION: April 2007
|SUBJECT:||REQUEST FOR ALTERNATIVE METHOD OF COMMUNICATIONS OF PROTECTED HEALTH INFORMATION|
Legal Representative means the person authorized by law to act on behalf of the patient, such as the parent of a minor, a court-appointed guardian or a person appointed by the patient in a Power of Attorney document.
Protected Health Information (PHI) means information that is part of an individual’s health information that identifies the individual or there is a reasonable basis to believe the information could be used to identify the individual, including demographic information, and that (i) relates to the past, present or future physical or mental health or condition of the individual; (ii) relates to the provision of health care services to the individual; or (iii) relates to the past, present, or future payment for the provision of health care services to an individual. This includes PHI which is recorded or transmitted in any form or medium (verbally, or in writing, or electronically). PHI excludes health information maintained in educational records covered by the federal Family Educational Rights Privacy Act and health information about UAMS employees maintained by UAMS in its role as an employer.
UAMS Workforce means for purposes of this Policy, physicians, employees, volunteers, trainees, and other persons whose conduct, in the performance of work for UAMS, is under the direct control of UAMS, whether or not they are paid by UAMS.
All patients or patient’s Legal Representatives may request the University of Arkansas for Medical Sciences (UAMS) to use alternative methods of communication, or alternative locations to receive communications or any other information from UAMS, containing the patient’s Protected Health Information (PHI). UAMS will honor requests which UAMS determines to be reasonable, and UAMS does not require the patient to disclose an explanation or reason for such request. If necessary, UAMS will require the patient to identify how payments will be made.
NUMBER: 3.1.18 DATE: 10/16/2002
Please complete this Form to request UAMS to communicate with you by alternative means or at an alternative location. For example: UAMS mail to be sent to a different address other than your home.
I, _____________________________________, request you communicate with me as indicated below:
PRINT Patient’s First and Last Name
I understand this request expires on _________________. If I wish to extend my request, I must submit another request in writing to:
UAMS HIPAA OFFICE
4301 West Markham St., #829
Little Rock, AR 72205-7199
I understand that requesting this alternative method of communication may interfere with UAMS’ ability to contact me in medical emergencies.
I understand and agree that, if I cannot be located by the alternative method requested, UAMS may use any available contact information to locate me in the event that (1) UAMS determines there is a medical emergency or similar situation in which my health is at risk if I am not contacted immediately; or (2) if I have not provided adequate information on how payments will be made.
Signature of Patient or Legal Representative Date
If Legal Representative, authority of Legal Representative _____________________________________________
(such as parent of a minor, court-appointed guardian, administrator of estate of deceased, attorney-in-fact appointed with power of attorney, or healthcare proxy)
For verification purposes, please include your date of birth: ______________/______/_______.
Month Day Year
Patient’s telephone number (for processing the Request): _____________________
For Staff Use Only
Request Denied If not approved, Patient was notified on .
UAMS Staff Signature and Date
NOTE: When using HBO/SMS billing systems, if the Patient and Guarantor are not the same, all billing information will continue to go to the Guarantor’s address.
EPF Bar Code HIPAA 3 of 3