Request Confidential Communications of PHI

This form allows the user to request a different address, phone number or email address for communication. Complete this form to add/omit the additional a confidential address and contact information. Once entered, the confidential contact information will be available to all providers using our record system. It is also the responsibility of the patient to inform all health care providers that are not users of HopeQure about the communication change request.

Tell us your name *

Enter your email *

Enter your Date of Birth *

Phone No *

Address

City

State

ZIP Code

Send the PHI to the following alternative telephonumber or email address:
Information Requested

Phone No *

Enter your email *

Address

City

State

ZIP Code

I hereby request confidential communication on the above provided communication details, terminating and restricting the initial recorded communication information.

I accept all the term & conditions written below.

I understand that my request will be processed within thirty (30)days. I understand if I checked the “I Agree” box above to review ONLY the information specified to be released. I understand that this request for release of information may be denied or reduced and only portions released. If so, I have the right to request a review of this decision by submitting my request online to the Privacy Office of HopeQure. I understand that on receieving the information Hooequre will hold no responsibility of the information access provided.

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