​This form lets you choose where your health information gets sent after your health care visit.  Right now, if you do not complete this form, your health information will be sent to the person who pays for the insurance you use.  You can ask that the information be sent to a different address or by other means that only you will see.  You can do this if you believe that giving your health information to the person paying for your insurance would put you in danger. Before sending this form to your insurance company, you may wish to contact your insurance company to see if it permits a request to be taken over the phone or by email.  If the insurance company requires a written request, complete this form and send it to your insurance company. ​

• Request for Confidential Communications Form 
• En Español​: Formulari​o de Solicitud de Comunicación Confidencial​​

For more information about health coverage, visit our website.