Form IHS-963 Request for Confidential Communication by Alternative Me

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.

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.

(Note: IHS is only able to send email through the IHS Secure Data Transfer System or RPMS Direct.

IHS is unable to approve text messaging as an alternate means of communication at this time)

Please describe in detail your proposed alternative means or alternate location for receiving communications from IHS:

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

Request Approved Denied If denied, reason (check one):

FOR IHS USE ONLY

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)} OMB STATEMENT

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0917-0030. The time required to complete this information collection is estimated to average less than 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Indian Health Service, OMS/DRPC, 5600 Fishers Lane, Rockville, MD 20857, Attention: Information Collections Clearance Officer..

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