You have the right to request that we communicate with you about the services you receive her in a method or at a location that is more confidential f...
Request by person served for confidential communications You have the right to request that we communicate with you about the services you receive her in a method or at a location that is more confidential for you. For example, you may ask that we contact you at work instead of at home. To request confidential communications, please complete and return this form. We will not ask you the reason for your request and we will try to accommodate all reasonable requests. Name of person served: __________________________________________________________ Last name First name MI Address: ______________________________________________________________________ Phone: __________________________________ (day)
Confidential communication requested: Please answer the following questions. You may attach a separate page if more space is needed. 1. What is the alternative method or location of communication that you are requesting? ______________________________________________________________________________ ______________________________________________________________________________ 2. How will payment (if any) be handled if we agree to communicate with you through this alternative method or location? For example, if you no longer wish to be contacted at home, should we send any requests for payment to your workplace? _________________________ _____________________________________________________________________________ By signing below, I am requesting that The Arc of Monroe County communicate with me through the alternative method or location explained above. I understand that communication in this manner will not occur unless my request is agree to by the agency. Please send completed for to: Privacy Officer The Arc of Monroe County 1000 Elmwood Ave, Suite 500 Rochester, NY 14620
Confidential communications form
1
The Arc of Monroe County, NYSARC, Inc
____________________________________________________ Printed name of person served or personal representative
__________________ Date
____________________________________________________ Signature of person served or personal representative
__________________ Date
____________________________________________________ Description of personal representative’s authority
__________________ Date
For Arc of Monroe County use only Date received: _____/_____/_____ Disposition of request: _____ Granted; _____ Denied; _____ Partially denied Person served notified in writing on this date: _____/_____/_____ Name of staff person processing this request: ______________________________________