Patient Communication Consent Form

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record #: ______________ Date: ____________________

Authorization for Communication

I hereby authorize [Practice Name] to communicate with me using the following methods regarding my personal health information, appointments, lab results, and other medical information:

Approved Communication Methods (check all that apply):

• Cell Phone: ________________

  • Voice Messages
  • Text Messages

• Home Phone: ________________

  • Voice Messages
  • Detailed Messages

• Email: ____________________

  • Appointment Reminders
  • Lab Results
  • General Medical Information

• Patient Portal

Authorized Individuals

I authorize the practice to discuss my medical information with:

1. Name: _________________ Relationship: _________ Phone: _________
2. Name: _________________ Relationship: _________ Phone: _________

Understanding and Agreement

• I understand that email and text communications are not encrypted and may pose security risks
• I acknowledge that messages may be inadvertently accessed by others
• I understand I can modify or revoke this consent at any time in writing
• This consent remains valid until explicitly revoked

Signature: _________________________ Date: ____________

For Office Use Only

Received by: _____________ Date: ____________ Entered in EHR: [ ] Yes [ ] No