This form allows the user to request a different address, phone number or email
address for communication. Complete this form to add/omit the additional a confidential
address and contact information. Once entered, the confidential contact information
will be available to all providers using our record system. It is also the responsibility
of the patient to inform all health care providers that are not users of HopeQure
about the communication change request.
I hereby request confidential communication on the above provided communication
details, terminating and restricting the initial recorded communication information.