Geriatric Patient Communication Authorization Form

Patient Information

Name: _________________________________ Date of Birth: _______________ Medical Record Number: __________________ Phone: _____________________

Authorization for Communication

I hereby authorize [Practice Name] to communicate regarding my medical care with the following individuals:

Primary Contact

Name: _________________________________ Relationship: ________________ Phone: _________________________________ Email: _____________________ □ Full access to medical information □ Emergency contact only □ Appointment scheduling only

Additional Authorized Contacts

1. Name: ______________________________ Relationship: ________________ Phone: ______________________________ Email: _____________________ □ Full access □ Emergency only □ Scheduling only

2. Name: ______________________________ Relationship: ________________ Phone: ______________________________ Email: _____________________ □ Full access □ Emergency only □ Scheduling only

Preferred Communication Methods

□ Phone call □ Text message □ Email □ Patient portal □ Mail

Special Instructions

□ Leave detailed voice messages □ Do not leave detailed messages □ Contact only through authorized representatives

Authorization Period

This authorization is valid until: □ One year □ Other: ________________

Understanding and Agreement

I understand that:

• I may revoke this authorization at any time in writing
• This authorization includes both medical and billing information unless otherwise specified
• Information shared may include sensitive health information

Patient/Legal Representative Signature: _______________ Date: __________

Print Name: ____________________________ Relationship: ______________

For Office Use Only

Received by: ___________________________ Date: ____________________ Scanned into EHR: □ Yes □ No Initial: ___________