Question

A Patient Privacy Questionnaire is completed by the patient to give consent, detailing to whom we can give paper copies of their medical records too.

Select one:
a. True
b. False

Answer 1

True

Explanation: This is what a questionnaire looks like.

May we leave confidential messages with anyone who answers the telephone at your

home? YES NO

2. May we leave confidential messages regarding appointment, return calls for test results,

etc. on your home answering machine or voicemail? YES NO

3. Is there a number other than your home number where we can leave a confidential

message with anyone answering the telephone regarding appointment, lab results, or

other healthcare information? (ex. Cell Phone) YES NO

If yes, please list number(s) (____) ________________; (____) _____________________

4. If we are unable to reach you by any of the above options, may we leave a confidential

message at your place of employment? YES NO

5. Is there anyone you wish we DO NOT disclose your medical information to? (i.e. Spouse,

Children, Parent(s), etc.) ___________________________________________________