Get Request For Confidential Communications And/or ... - Northwell Health

Filling out the Request For Confidential Communications And/or Restrictions form is an important step in managing your Protected Health Information with Northwell Health. This guide will provide a clear and supportive approach to completing the form accurately and efficiently.

Follow these steps to complete your request.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by entering your name in the 'Patient Name' field. Ensure that the name is printed clearly as it appears in your medical records.
3. Next, enter your date of birth in the designated field. This information helps identify you in the healthcare system.
4. Indicate the location(s) where you receive medical treatment by providing the relevant details in the appropriate section.
5. If you are requesting a restriction on the use, access, or disclosure of your health information, check the corresponding box and describe the requested restriction, including the person or entity involved and the type of information that should be restricted.
6. If you want to request confidential communication, please check the box for 'CONFIDENTIAL COMMUNICATION REQUESTED' and fill out the alternative contact information, including the street address, suite or apartment number if applicable, city, state, zip code, and phone number.
7. Sign the form in the designated area. If you are a personal representative, ensure that you provide your relationship to the patient.
8. Complete the date and time section. If applicable, provide the telephonic interpreter’s ID number or have the interpreter sign and print their name along with their relationship to the patient.
9. Once all fields are completed, review the form for accuracy. You can then save changes, download a copy, print it, or share the completed form as necessary.

Complete your Request For Confidential Communications And/or Restrictions online today to ensure your health information is handled according to your preferences.