JAMES D CHARASIKA, M.D.
Marriage and Family Therapists at Dupont Cir, Louisville, KY

2005019, Sep 8, 2005

Mar 8, 2004

10/708498

James Charasika - Louisville KY, US

LOUISVILLE PRIMARY CARE - Louisville KY

B42D015/00

462028000

The present invention relates to a system and method for selective collection of confidential information comprising a plurality of overlapping stacked complete information collection sheets, which are overlying a reproduction enabling media, which is overlying a record data sheet. Each of the plurality of complete information collection sheets includes a select information portion in communication with the reproduction enabling media, and a portion for collecting nonselective information not in communication with the reproduction enabling media. Thus, only the information provided with respect to the select information of each of the plurality of complete collection sheets is reproduced on the record data sheet for later review. The select information is correlated to a unique information identifier when reproduced on the record data sheet. When entered into a data storage database, the unique identifier may be used to reference or recall any portion of the complete information provided.