Patient Communication Authorization Form

Patient Information

Name: _____________________________ Date of Birth: _______________ Medical Record Number: _______________ Phone: ____________________

Authorization for Information Release

I hereby authorize [Practice Name] to share my medical information with:

Authorized Individuals

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

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

Communication Preferences

Preferred Contact Method (check all that apply)

□ Cell Phone □ Home Phone □ Work Phone □ Email □ Patient Portal □ Mail

Voicemail Authorization

May we leave detailed messages about your medical care? □ Yes □ No

Electronic Communication Consent

I understand that electronic communication may not be secure and authorize communication via: □ Email □ Text Message □ Patient Portal

Information Sharing Specifications

This authorization applies to: □ All medical information □ Test results only □ Appointment information only □ Billing information only □ Other (specify): ____________________

Duration & Revocation

This authorization remains valid until: □ One year from date signed □ Other date: _______________

I understand I may revoke this authorization at any time by submitting a written request.

Signature

Patient/Legal Guardian: _________________________ Date: __________

Witness: _____________________________________ Date: __________