621 Request Alternative Communication
621 Request Alternative Communication
621 Request Alternative Communication
2.
_______________________________________________________________________
Please do NOT send postal mail to this address: _______________________________
3.
________________________________________________
_______________
Date
_________________________________________
Printed name of client or personal representative
___________________________
Relationship to the client
________________________________________________________________________
Description of personal representatives authority
Accepted
Refused
Reason(s): ______________________________________________________________
_______________________________________________________________________
_____________________________
Printed name of Privacy Officer
__________________________ ___________
Signature
Date