Patient Communication Consent Form

Authorization for Electronic and Alternative Communication Methods

I, _________________________________ (print name), authorize [Practice Name] to communicate with me using the following methods regarding my medical care, appointments, test results, prescriptions, and other healthcare information:

Approved Communication Methods

(Check all that apply)

• Cell Phone: (__) -

  • Voice Messages
  • Text Messages

• Home Phone: (__) -

  • Voice Messages
  • Detailed Messages

• Email: _________________________

• Patient Portal

Authorized Individuals

I authorize communication about my medical care with the following individuals:

1. Name: _________________________ Relationship: _____________ Phone: (__) - Email: _________________________

2. Name: _________________________ Relationship: _____________ Phone: (__) - Email: _________________________

Acknowledgments

• I understand that email and text messaging are not confidential methods of communication and may be insecure
• I understand that there is a risk that protected health information transmitted electronically may be viewed by unauthorized parties
• I acknowledge that urgent or emergency situations should not be handled through email or text messaging
• I understand that I may revoke this consent in writing at any time

Signature: _________________________ Date: //___

Print Name: _________________________ DOB: //___