Authorization for Release of Medical Information and Communication Preferences

Patient Information

Name: _________________________ Date of Birth: _________________ Medical Record #: ______________ Phone: _________________________

Communication Authorization

I, _________________________, authorize [Practice Name] to discuss my medical information with:

Authorized Individuals

1. Name: ______________________ Relationship: ___________________ Phone: _____________________ Access Level: □ Full □ Limited

2. Name: ______________________ Relationship: ___________________ Phone: _____________________ Access Level: □ Full □ Limited

Preferred Communication Methods

Please check all that apply:

□ Cell Phone: _________________ □ Home Phone: ________________ □ Work Phone: ________________ □ Email: _____________________ □ Patient Portal □ Text Message

Voice Message Authorization

I authorize detailed messages to be left on my voicemail: □ Yes □ No

Electronic Communication Consent

I understand that electronic communication may not be secure and authorize its use: □ Yes □ No

Emergency Contact

Name: ________________________ Phone: ________________________ Relationship: __________________

Acknowledgment

I understand that:

• This authorization remains valid until revoked in writing
• I may revoke this authorization at any time
• This authorization includes post-operative care communication
• Emergency communications may occur through any available means

Signature: _____________________ Date: ________________________

Practice Representative: _________ Date: ________________________