DEPARTMENT OF HEALTH AND HUMAN SERVICES
Indian Health Service
REQUEST FOR CONFIDENTIAL COMMUNICATION BY
ALTERNATIVE MEANS OR ALTERNATE LOCATION
I, , Date of Birth request an alternative means of
communication of my health information (e.g., regular mail, telephone, facsimile) or communication of my health
information to an alternate location.
(Note: IHS is unable to accept e-mail addresses as an alternative means of communication at this time.)
I understand that request for communication by alternative means or to an alternate location is applicable only to
information held by the Indian Health Service (IHS) and disclosure by alternative means may not be protected and
could endanger me. I understand that request for FAX communication may be intercepted by others and IHS is not
responsible if such intercepts occur.
Please describe in detail your proposed alternative means or alternate location for receiving communications from IHS:
Alternate Mailing Address:
Alternate Phone Number:
Alternate Means of Contact (Please Specify):
This request applies to the following information: Today’s Date of Service only
From:
To:
From: Until Further Notice
SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE
(If Personal Representative, state relationship to patient)
DATE
SIGNATURE OF WITNESS (If signature of patient is a thumbprint or mark)
DATE
FOR IHS USE ONLY
Request Approved
Denied
If denied, reason (check one):
Request is not reasonable to accommodate Alternate address or contact not provided
Failure to provide information on how payment will be made (if applicable)
Other (please explain):
IHS-963 (4/09)
PSC Publishing Services (301) 443-6740
EF
