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Indian Health Service The Federal Health Program for American Indians and Alaska Natives


     Indian Health Manual
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Part 2, Chapter 7:  Manual Exhibit 2-7-C

Policy and Procedure for the Transmittal of
Confidential Communication by Alternate Means or to an
Alternate Location


  1. PURPOSE.  The purpose of this Manual Exhibit is to publish the policy and procedure for allowing patients to request the transmission of protected health information (PHI) by alternate means or to an alternate location.

  2. AUTHORITY.

    1. 45 Code of Federal Regulations (CFR) 164.522(b)(1) and (2)

  3. POLICY.  An individual has the right to request the transmission of PHI by alternate means or to an alternate location if the individual makes a written request and the request is reasonable.

  4. DEFINITIONS.

    1. Alternate Means.  Alternate means are methods of sending confidential communications that are different from the usual methods e.g., registered mail, facsimile, e-mail (if encrypted/secured), etc.

    2. Alternate Location.  Alternate location means an address different from that listed as the mailing address in the Indian Health Service (IHS) record.  For example, the patient can ask the IHS to contact him or her at work, instead of at home, or vice versa.

    3. Confidential Communications.  Confidential communications means transmission of a patient's PHI from the IHS.

  5. PROCEDURES.  The following procedures will be used when patients request transmission of PHI by alternate means or to an alternate location.

    1. All requests for confidential communications to be sent by alternate means or to an alternate location shall be in writing and must describe the alternate means or the alternate location.

    2. The Chief Executive Officer (CEO) or designee will approve or disapprove all requests.  (For Areas that provide Contract Health Service directly through the Area Office, references to the CEO should be considered references to the Area Director's designee, as applicable.)  Whenever possible, the decision will be given to the patient prior to the patient leaving the facility.  The CEO or designee will approve the request if it is reasonable.

    3. A written request or the IHS 963, (See Appendix 1) must be completed to ensure appropriate documentation.

    4. Requests will be filed or documented in the medical record after the patient has been notified of the decision.

Manual Exhibit 2-7-C

This is not an exact replica of the Appendix 1

Appendix 1

Indian Health Service
Request for Confidential Communication by Alternate Means or to an Alternate Location

I, __________________________________________________ , Date of Birth ____________________ request for alternate means of communication of my health information that are different from the usual method, e.g., regular mail, facsimile, address, e-mail (if encrypted/secured), etc.  [I understand that request for communication by alternate means or to an alternate location is applicable only to information held by the Indian Health Service (IHS) and disclosure by alternate means may not be protected and could endanger me.  I also understand that request for email and or fax communication may be intercepted by others and IHS is not responsible if such intercepts occur.]

Please describe in detail your proposed alternate means or to an alternate location for receiving communications from IHS:

Alternate Mailing Address: ..........................................................................................................................................................................

..........................................................................................................................................................................

..........................................................................................................................................................................

Alternate Phone Number: ..........................................................................................................................................................................
Other Alternate Means of Contact (Please specify): ..........................................................................................................................................................................

This request applies to the following information:

Today's Date of Service only.
From.........................To...........................
From.........................Until Further Notice

__________________________________________________________________
Patient Signature or Personnel Representative
________________________________________
Date

(For IHS use only)

Request Approved...........................Denied................................

If denied, reason for denial (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)

_________________________________________________________________________________
Signature of Employee    Title    Date


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