Cardiac Surgery Patient Communication Authorization Form

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record Number: __________ Phone: ____________________

Authorization for Communication

I, _________________________________, authorize the Cardiac Surgery Department at [Hospital Name] to:

Approved Methods of Communication

• Leave detailed voice messages regarding my cardiac care
• Send text messages for appointment reminders
• Communicate via email at: ____________________________
• Use patient portal for secure messaging

Authorized Individual(s) for Medical Information Release

1. Name: _________________________ Relationship: _______________ Phone: ________________________ Access Level: □ Full □ Limited

2. Name: _________________________ Relationship: _______________ Phone: ________________________ Access Level: □ Full □ Limited

Information Authorized for Release (check all that apply)

• Test results
• Surgical scheduling
• Medication information
• Post-operative care instructions
• Billing information

Emergency Contact Information

Primary Contact: _________________ Phone: ____________________ Relationship: ____________________

Acknowledgment

I understand that:

• This authorization remains valid until revoked in writing
• I may revoke this authorization at any time by submitting a written request
• This authorization is voluntary
• Information disclosed may be subject to redisclosure by the recipient

Patient Signature: _________________ Date: ____________________

Witness Signature: _________________ Date: ____________________