Retain for a minimum of 6 years
City State Zip
Communication made after this date:**
_________________________________________
Request APPROVED
_
____________________________________
Signature
Date
Apt. #
Cameron University
Health Plan
Route To:
[X]
Member Name:
Billing
Request for Alternative Means of Communication Health Plan
Date of Birth: Member ID#:
Member Address:
Street
Member Work Phone #:
Member Home Phone #:
NOTICE TO MEMBER: Your request for communication by alternative means is applicable only to the information maintained by the Cameron University Health Plan.
If you would like an alternative means of communications from any other University entity, a separate request must be submitted to that University entity. (This
request is applicable only to communications made by the Cameron Health Plan.)
REQUESTED ALTERNATIVE MEANS OF COMMUNICATION (check applicable box and fill in the blank):
Alternative Mailing Address:
Other Alternative Means of Communication:
If you believe that disclosure of part or all of your information could put you in danger, please provide a statement to that effect:
My request applies to:
Signature Title, if legal representative* Date
*
May be requested to submit evidence of representative status
Alternative Phone Number:
( )
Request DENIED
By:
Title
Reason for Denial:
Too expensive to accommodate request.
Administratively impractical to accommodate request.
You did not specify an alternative address or method of communication.
Additional Explanation:
Notice of Denied requests should be given to the Member during the office visit or sent via the alternative means above.
**In most cases, changing means of communication, if approved, may take up to 14 University business days.
File in Member Chart HIPAA Document
Rev. 02/2016 © 2015 Retain for a minimum of 6 years
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