Patient Authorization of Disclosure  Home 5 Patient Authorization of Disclosure In general, the HIPAA Privacy Rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications of PHI be made by alternative means, such as sending correspondence to the individual's office instead of the individual's home. The patient may revoke or change this authorization at any time with a written request.I wish to be contacted in the following manner (Check all that apply):* Home Telephone Work Telephone Written Communication Other Home Phone*How do you want us to leave a message?*OK to leave message with detailed informationleave message with call-back number onlyWork Phone*How do you want us to leave a message?*OK to leave message with detailed informationleave message with call-back number onlyWhere do you want it sent?* OK to mail to my home address OK to mail to my work/office address OK to fax Fax NumberIf Other, Please specify belowIn a further effort to protect your health information and the confidentiality of you healthcare, we ask that you designate below to whom the physicians and staff at Neurology Consultants of Nebraska, P.C. may discuss your healthcare and scheduling needs as well as billing issues that may arise.I allow you to give my clinical and/or financial information to or answer questions from (Check all that apply) Spouse Parent Child Other (specify) Only disclose information to myself Spouse Name First Last Parent Name First Last Child Name First Last If Other, please specify belowAt any time you may revoke or terminate this authorization by submitting a written revocation to Neurology Consultants of Nebraska, P.C. However, your written revocation will not affect any disclosures of your medical information that the person(s) and/or organization(s) listed above have already made, in reliance of this authorization, before the time you revoke it.Patient Signature (Type Your Name)* Today's Date* MM slash DD slash YYYY Your Date of Birth* MM slash DD slash YYYY
