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Request for Alternate Communication

The primary forms of communication for therapy services are telephone, fax, face-to-face conversation, or Telehealth because these methods can assure reasonable confidentiality. Some clients and guardians prefer to use other means of communication for quicker or easier contact. Completion of this form will allow some specific alternative means of communication. Please note that when email or text services are used, OCP has no ability to assure security, confidentiality, or encryption of the content. These means of communication can be used with client/guardian permission, but are often not secure to the standards of HIPAA Omnibus Rule of 2013.

Please note that we will not ask you why you are requesting alternative communications. Also, we may be unable to agree to accommodate your request (i.e. it is unreasonable, we do not have the technology, in an emergency). We may deliver your electronic request in the format you request, or if we do not have the software to accommodate that, in a similar electronic format. If we agree to your request, we will follow the instructions stated below until such time as you instruct us otherwise in writing. A signed, dated copy of this Request shall be as effective as the original.

COMPLETE AS APPLICABLE:

This request pertains to the records of

I am requesting the following alternative communications in addition to the primary methods listed above:

Appointment Reminders Email Contact Text Messaging Other

Please accept this as a formal request for communication dated

Patient Name:

By Patient’s Representative:

(Phone Number)

OFFICE USE ONLY

Describe what alternative communications were denied this ______ day of _______________, 20________

___________________________________________________________________________________________________

Describe what alternative communications were accepted this ______ day of ____________, 20_________

___________________________________________________________________________________________________

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

March 22, 2020 9:55 am PDT

Request for Alternate Communication Uploaded by OCP Documents - ocpdocs@oregoncp.org IP 10.0.10.40

March 25, 2020 5:02 pm PDT