PATIENT RECORD OF DISCLOSURES 
       Patient Name: _____________________________________DOB:______________
I wish to be contacted in the following manner (check all that apply)

•	Written Communication
•	O.K. to mail to my home address 
•	O.K. to mail to my work address
•	O.K. to fax to this number

•	     Other _______________________________
           ____________________________________________

•	 Home Telephone________________________
•	O.K. to leave message with detailed information 
•	Leave message with call-back number only

•	Work Telephone_________________________
•	O.K. to leave message with detailed information
•	Leave message with call back number only

Signature:_____________________________________________ Date:________________________________________

For Office Use Only
Record of Disclosures of Protected Health Information
Date	Disclosed To	(1)	Purpose of Disclosure	By whom Disclosed	(2)	(3)	

							

							

							

(1)                    Check this box if the disclosure is authorized
(2)                    Type key:   T-Treatment Records; P-Payment Information; H-Healthcare Operations
(3)                    Method Disclosure was made:   F-Fax; P-Phone; E-E-mail; O-Other