Confidential Communications Request

TO: Privacy Officer, America’s Best Vision Plan
1202 Monte Vista Avenue, Suite 17, Upland, CA 91786

FROM:

Your Name *

Your Date of Birth * (MM/DD/YYYY)

I am contacting you to request that all medical information related to sensitive services I receive arranged by America’s Best Vision Plan including where and when I receive health care be sent directly to me and not to my family members. ("Sensitive services" include sexual and reproductive health care, mental health, sexual assault counseling and care and treatment for alcohol and drug use.)

I request that communications containing any of the above information be sent to me as available as follows:

Please mark the way(s) that are safe for you to receive information.

Email to the following email address:

Message through my online ABVP patient portal:

Text to the following telephone #:

U.S. Mail at the address below:

Other (please describe):

IMPORTANT! The following two sections MUST be completed:

1. If a communication cannot be sent in the above selected format(s) and/or I prefer receiving information by U.S. mail, please use the address below:
2. Is there a phone number or email we can use to contact you if we have questions regarding this request?

This request is valid until I submit a revocation or a new request.

Enter the code shown above in the box below.