Alternative Communication Request

To request an alternative form of communication from Hill Physicians, please complete and submit the request form.

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Is this request for yourself?(Required)

Yes, this request is for myself

No, this request is on behalf of someone

Individual’s First and Last Name(Required)

Prefix First Last

I am the authorized representative of:(Required)

I am submitting this request for an alternative method of communication for and on behalf of the above Individual for the following reason:

Individual's Health Plan Member No.(Required)

I request that Hill Physicians Medical Group, and any of its business associates, who has or will have a need to communicate with the above name Individual for any reason, to do so in the following manner or to the following location:(Required)

Contact me by mail (Please specify)

Contact me by phone (Please specify)

Contact me by email (Please specify)

If by mail, please forward any information to the following address:(Required)

*Please specify address here

If contact is made by telephone, please contact me or my representative at:(Required)

*Please specify phone number here

If contact is made by e-mail, please contact me at:(Required)

*Please specify e-mail address here

Consent(Required)

The request for an alternative method of communication between Hill Physicians Medical Group and myself is made on the belief that disclosure of this information in the normal course of business may endanger my welfare.

Consent(Required)

I understand that Hill Physicians may not accept my request for an alternative method of communication if the request is unreasonable, as determined by Hill Physicians, or could not be reasonably accommodated in the normal course of business.

Dated(Required)

Signature(Required)

Please print your full name here

Your Title(Required)

Please enter your title here

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