NUMBER: 3.1.20
DATE: 04/01/03
REVISION: 03/01/04




UAMS Physicians, Faculty, Employees and Volunteers.


Unless the patient requests UAMS not to disclose Patient Directory Information, UAMS may provide Patient Directory Information to a person provided that the caller or requesting party specifies the patient name.

1.                  Patient Directory Information is limited to the following:

         Patient name

         Location in the facility

         One word statement of condition that does not communicate specific medical information about the patient – to be released by UAMS Medical Center Patient Care Team or Office of Communications and Marketing.  University Hospital and Clinical Programs Professional Nursing Organization Policy Standards, Patient Confidentiality, J.4.

         Religious affiliation – only released to members of the Clergy

2.                  Patients may restrict or prohibit release of their information from the Directory.

3.                  UAMS may release the patient’s religious affiliation, if given to UAMS by the patient, only to members of the Clergy.  Members of the Clergy do not have to specify patient name to request Patient Directory Information.  Clergy requests for a list of patients by denomination will be handled by the Office of Pastoral Care at (501) 686-5410.

4.                  Members of the media who request Patient Directory Information will be referred to the UAMS Office of Communications and Marketing, (501) 686-8149 or (501) 395-5989 in accordance with Media Relations and Release of Information, Policy A.2.01.

UAMS may elect on its own, without a patient’s request, to exclude certain patients from the Directory and not release any information. Examples are when the safety/security of patients or others are at risk, or at the request of the UAMS Special Services Office.



1.                  The UAMS workforce should reference the UAMS Notice of Privacy Practices Policy to inform the patients about the information in the Directory and to describe how this information may be disclosed.                                                                                                                                                    

2.                  The UAMS Notice of Privacy Practices Policy will inform patients of their rights to omit some or all of their information for directory purposes.

3.                  The “Request to be Excluded from the Patient Directory” form must be maintained for patients who object to any or all of their information being included in the Directory, or if UAMS determines that the patient should be excluded.  UAMS will “flag” directory listings and other applicable records to indicate exclusions have been requested. 

4.                  Requests for a patient condition will be referred to the nursing unit except for requests from members of the media. Media Relations and Release of Information, Policy A.2.01.

5.                  Individuals who identify themselves as members of the media will be referred to the UAMS Office of Communications and Marketing.


6.                  All other requests for Patient Directory information at UAMS Medical Center must be provided via the HBOC Medipac INFO (Information Desk Inquiry) screen, the Patient Information Screen in OSCAR, by another officially approved mechanism, or by calling Patient Information at (501) 686-6416.

7.                  If the patient is incapacitated or in an emergency treatment situation, UAMS may use or disclose some or all of the information in the Directory provided the disclosure is:

         Consistent with a known, prior expressed preference of the patient; and

         UAMS determines it is in the patient's best interest.

When it becomes practical to do so, UAMS will inform these patients about the uses and disclosures for Directory purposes and offer them the opportunity to decline inclusion in the Directory.

Request to be Excluded from the Patient Directory

If I am a patient at this facility, I understand that the following information in the facility’s Patient Directory is available to any person who asks for me by name:

(1) my name;

(2) my location in the hospital or clinic location; and

(3) a one word statement of my general medical condition (such as good, fair, serious,     critical),  without any other specific medical information.

I also understand that members of the clergy may receive this information, along with my religious affiliation, even if they do not ask for me by name.


    [   ] I do not wish to be included in the Patient Directory. I understand that my exclusion from the Patient Directory will keep this facility from releasing my room number or clinic location to florists, friends, and family and from transferring phone calls to my room.                                                                  OR

 [   ] I agree that my name can be listed in the Patient Directory, but I want to restrict the release of the following  information from the Patient Directory: (check all that apply)

[   ] Do not provide my room number or clinic location.

[   ] Do not provide a one word statement of condition (such as fair, serious, critical)

[   ] Do not provide my religious affiliation

I understand that the above restrictions will apply only to this visit or admission, and that I must request restrictions again at future visits if I want any restrictions to be in effect. 

Date of admission or clinic visit             Signature of patient or representative     Today’s date



[    ] Verbal  request and the patient or representative was not available to fill out this  form.

[  ] If a request to exclude  information from the Patient Directory is initiated by UAMS, instead of by the patient or a patient’s representative, check this box and sign/date below.  ___________________________________________                                               UAMS employee making the request                                                     Date


[   ] Patient or UAMS request received and documented in


UAMS Signature                                                                                   Date

EPF Barcode          HIPAA