Request to Restrict Use & Disclosure of Health Information

The Counseling Center

of Wayne and Holmes Counties

Est. 1953 ~ Over 50 years of service excellence!

Request to Restrict Confidential Communication

SECTION A: Client to complete the following information.

NAME:______________________________________________ BIRTH DATE:_____________________

ADDRESS:____________________________________________________________________________

TELEPHONE:_________________________________________ DATE:___________________________

I hereby request to receive confidential communications from The Counseling Center regarding my health condition, care, treatment, services, and/or payment in the following alternative manner and method (check all that apply):

    At a telephone number other than my home number. Telephone number is: ______________________

    At a mailing address other than my home mailing address. Requested mailing address is: _____________________________________________________________________________________

_____________________________________________________________________________________

   Via e-mail. My e-mail address is: _________________________________________________________

   Other. Please specify: __________________________________________________________________

I understand that, if The Counseling Center agrees to provide me with confidential communications regarding my health care via the above-identified alternative manner and method, The Center may condition agreement upon the following:

a.    The receipt of information from me as to how payment for The Counseling Center’s services will be

       handled.

b.    The specification of an alternative address or other method of contact.

Signature______________________________________________   Date ________________

Signature of Parent

or Guardian____________________________________________    Date ________________

SECTION B: The Counseling Center to complete the following.

The above request regarding confidential communications via an alternative manner and method has been reviewed

by The Counseling Center and has been:

         Accepted                         Denied (The Center cannot reasonably accommodate request.)

        Comments:

_________________________________________________________    _____________________

Diane S. DeRue, MPA, LSW                                                            Date

Compliance and Privacy Officer

Directions for printing the HIPAA forms.

Click on the Print button in the task bar of your Internet browser. If your print button does not work please us the following steps.

Step 1. Right click on the mouse and in the menu that appears, left click on the "Select All" option.

Step 2. When the text is highlighted, right click on the mouse once again and in the menu that appears, left click on the "Copy" option.

Step 3. Right click on the mouse and in the menu that appears, left click on the "Print" option.

Forms to request changes, corrections and/or copies of your clinical record are also available from the Corporate Compliance and Privacy Officer, Medical Records or any Counseling Center office.