Malibu Specialty Center
28990 Pacific Coast Highway Suite 222
Malibu, California, 90265
3104574898

PATIENT RECORD OF DISCLOSURES

In general, the HIPAA privacy rules gives individuals the right to request 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_____________________
    •  OK to leave message with detailed information
    •  Leave message with call-back number only.
  •  Work Telephone______________________
    •  Ok to leave messge with detailed information.
    •  Leave message with call-back number only.
  •  Written Communication
    •  OK to mail to my home address
    •  OK to mail to my work/office address
    •  OK to fax to this number ______________________________
  •  Other

Patient Signature
Date

 

Print Name
Birthdate

 

CML-025