Consent for Communication and Information Release

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record #: ________________

Authorization for Communication

I, _________________________________, authorize [Practice Name] to communicate regarding my medical care and release my protected health information to the following individuals:

Authorized Contacts

1. Name: _________________________ Relationship: _____________ Phone: _________________________ □ Medical Information □ Billing Information □ Appointment Details

2. Name: _________________________ Relationship: _____________ Phone: _________________________ □ Medical Information □ Billing Information □ Appointment Details

Communication Preferences

Please select your preferred methods of communication:

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

Voice Message Authorization

I authorize [Practice Name] to leave detailed messages containing medical information on my: □ Cell Phone Voicemail □ Home Phone Voicemail

Emergency Contact

Name: _________________________ Relationship: _____________ Phone: _________________________

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 practice cannot control information after it has been released
• All released information will be handled confidentially under HIPAA guidelines

Signature: ______________________ Date: ______________

Print Name: _____________________

For Office Use Only Received by: _____________ Date: _____________ Scanned to EMR: □ Yes □ No