Request for Alternative Method of Communications of Protected Health Information

1. Request for Alternative Method of Communications of Protected Health Information Policy 3.1.18 in the UAMS Administrative Guide Created by CCTC

2. If the patient wants to be contacted at an address and phone other than their home phone and address (Adr1 on the Person Information I Screen), the information should be entered in the temporary address and phone field. This will be the only phone and address we will use for communications. Created by CCTC

3. If the patient wants to be contacted at an address and phone other than their home phone and address (Adr1 on the Person Information I Screen), the information should be entered in the temporary address and phone field. This will be the only phone and address we will use for communications.

4. The Form • The completed form will be scanned into the EPF in the “HIPAA “ document type. • Patients requesting these alternate communications will be required to fill out the Alternative method of Communications Request Form. • The request must be approved by the clinic or department manager or their designee. Created by CCTC

5. If the patient requests their mail (appointment reminders, bills, etc.) go to an address other than home address, the temp address field should be used. The “effective and thru” dates must be completed and mail will route to that address until such time the thru date has passed. A complete address must be entered. Created by CCTC

6. A comment must be made in CPI regarding the Temp address field: Patient has requested use of Temp Adr. Requests for Alternative Communication Form sent to EPF. Initials/location and phone number, Created by CCTC

7. A flag will display on the Person Information I Screen to alert users that information is in the Temp. address field on Person Information II Screen. Created by CCTC

8. If the patient is the guarantor, bills and appt reminders will go to address indicated in Temp.field for the duration of the effective dates Created by CCTC

9. If the patient is the guarantor, bills and appt reminders will go to address indicated in Temp.field for the duration of the effective dates

10. If the guarantor is someone other than the patient, the hospital/physician bills will go to the address listed in the guarantor’s CPI address field. Alternate mailing requests regarding the bill cannot be honored in those instances since they would impact the guarantor’s CPI. However, the appointment reminders can go to the alternate address. Created by CCTC

11. If the guarantor is someone other than the patient, the hospital/physician bills will go to the address listed in the guarantor’s CPI address field. Alternate mailing requests regarding the bill cannot be honored in those instances since they would impact the guarantor’s CPI. However, the appointment reminders can go to the alternate address.

12. 0108 41 28 3 1176 LE, VICTOR NC *1278 N. Ear Lane OQ CONWAY AR 72033 01011950 MO 501 871-4721 DORNHOFFER, J 003072 CONTRACT CR 06/07/01 2A 863845 The Patient Label If information is in the Temp. address field, it will “pull to the patient label”. An asterisk on the left side of the address will indicate that it is from the temp address field. Created by CCTC Created by CCTC

13. The Patient Label 0108 41 28 3 1176 LE, VICTOR NC *1278 N. Ear Lane OQ CONWAY AR 72033 01011950 MO 501 871-4721 DORNHOFFER, J 003072 CONTRACT CR 06/07/01 OTO 863845 If information is in the Temp. address field, it will “pull to the patient label”. An asterisk on the left side of the address will indicate that it is from the temp address field.

14. The patient may request that their regular address be used for mail but that they be called at an alternative phone number. The patient’s phone number should be entered into the Temp. address field. Retype the patient’s address from the Person Information I Screen into the temporary address field. If any field in the temp address is populated, all temp fields must be filled with valid data. Created by CCTC

15. The patient may request that their regular address be used for mail but that they be called at an alternative phone number. The patient’s phone number should be entered into the Temp. address field. Retype the patient’s information from the Adr1 on Person Information I Screen into the temporary address field. If any field in the temp address is populated, all temp fields must be filled with valid data.

16. The Temp. Address fields should only be used if the patient wants all written and/or oral communications to go to that location. • It can not be visit specific. • If the patient is the guarantor and the effective dates are current, all correspondence will be directed to The temp. address. • If the patient is not the guarantor, all information except for billing info will be sent to the Temp. address. Created by CCTC

17. Communicating with Patients • Employees communicating with patients must take care to use any current information present in the Temp. fields for those communications. • Supervisory approval must be obtained prior to using any information outside of the Temp. fields to contact the patient. The CPI comments may be checked for additional clarification. • Remember CPI Comments are global across the patient’s account and may be seen by many system Users. Created by CCTC

18. Alternative Communications Recap • If the patient asks to be contacted somewhere besides their home address and home/work phone numbers, enter that information in the temporary address fields. • Be sure and enter a complete and accurate address and effective from and thru dates. 3. If current information is in the temp fields, use it to contact patients.