Patient Communication Consent Form

Authorization for Electronic and Other Communications

I, _____________________ (print name), authorize [Practice Name] to contact me and communicate my protected health information through the following methods:

Electronic Communications

• Email communications at: _____________________
• Text messages at: _____________________
• Voice messages at: _____________________
• Patient portal messages

Appointment Reminders

• Email
• Text message
• Voice call
• Physical mail

Communication with Others

I authorize the practice to discuss my healthcare information with:

1. Name: _____________________ Relationship: _____________________ Phone: _____________________

2. Name: _____________________ Relationship: _____________________ Phone: _____________________

Understanding and Acknowledgment

• I understand that email and text communications are not secure and may be intercepted by unauthorized parties
• I accept the risks associated with these communication methods
• I understand I can revoke this consent at any time in writing
• This consent remains valid until revoked or modified in writing

Signature: _____________________ Date: _____________________

For Office Use Only

Received by: _____________________ Date: _____________________ Entered in EHR: [ ] Yes [ ] No