Request for Alternative Communications

Request for Alternative Communications
You have the right to request Stark Medical Specialties to communicate with you about your protected health information by alternative means or at alternative locations. The request must be made in writing by completing this form.

Stark Medical Specialties must comply with your request if it is administratively reasonable for Stark Medical Specialties to communicate with you in the manner you requested. Stark Medical Specialties will notify you in writing within thirty (30) days of receiving your request whether it will abide by your request. Stark Medical Specialties may condtion your request by requiring information as to how payment will be handled and specifications of an alternative address or manner of contact.

If you have questions regarding your rights or how to complete this form, please contact the Privacy Officer at (330) 837-1111.
Client Name*
Date of Birth*

MonthDayYear
Social Security Number
Address
Home Phone
Cell Phone
Work Phone
Please specify the manner in which you request Stark Medical Specialties to communicate with you regarding your protected health information:

Phone MessageFaxAnswering MachineRelativeOther
Fax Number
Name of Relative
Relative's Phone Number
Name of Other
Other's Phone Number
Client/Representative Signature*

Clear
Representative's Relationship to Client (If Necessary):
Date

MonthDayYear
Q
K
Bundle
Should be Empty: