Form IHS-963 Request for Confidential Communication by Alternative Means or Alternate Location

Form IHS-963 is a U.S. Department of Health and Human Services - Indian Health Service form also known as the "Request For Confidential Communication By Alternative Means Or Alternate Location". The latest edition of the form was released in April 1, 2009 and is available for digital filing.

Download a fillable PDF version of the Form IHS-963 down below or find it on U.S. Department of Health and Human Services - Indian Health Service Forms website.

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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 unable to accept e-mail addresses as an alternative means of communication at this time.)
Please describe in detail your proposed alternative means or alternate location for receiving communications from IHS:
Alternate Mailing Address:
Alternate Phone Number:
Alternate Means of Contact (Please Specify):
This request applies to the following information:
Today’s Date of Service only
To:
From:
From:
Until Further Notice
SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE
DATE
(If Personal Representative, state relationship to patient)
DATE
SIGNATURE OF WITNESS (If signature of patient is a thumbprint or mark)
FOR IHS USE ONLY
Request Approved
Denied
If denied, reason (check one):
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):
EF
PSC Publishing Services (301) 443-6740
IHS-963 (4/09)
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 unable to accept e-mail addresses as an alternative means of communication at this time.)
Please describe in detail your proposed alternative means or alternate location for receiving communications from IHS:
Alternate Mailing Address:
Alternate Phone Number:
Alternate Means of Contact (Please Specify):
This request applies to the following information:
Today’s Date of Service only
To:
From:
From:
Until Further Notice
SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE
DATE
(If Personal Representative, state relationship to patient)
DATE
SIGNATURE OF WITNESS (If signature of patient is a thumbprint or mark)
FOR IHS USE ONLY
Request Approved
Denied
If denied, reason (check one):
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):
EF
PSC Publishing Services (301) 443-6740
IHS-963 (4/09)

Download Form IHS-963 Request for Confidential Communication by Alternative Means or Alternate Location

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