Patient Communication Consent Form - Endocrinology Practice

Patient Information

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

Communication Preferences

I, _________________________, authorize [Practice Name] to communicate with me using the following methods regarding my medical care, lab results, appointments, and billing matters:

Approved Communication Methods (check all that apply):

□ Cell Phone: (_____) _______________

• □ Voice Messages
• □ Text Messages

□ Home Phone: (_____) _______________

• □ Voice Messages
• □ Detailed Messages

□ Email: ____________________________

□ Patient Portal

Authorization for Communication with Others

I authorize the practice to discuss my medical information with:

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

Specific Authorizations

• □ I authorize the discussion of my diabetes management plan
• □ I authorize the discussion of my thyroid condition
• □ I authorize the discussion of my medication adjustments
• □ I authorize the discussion of my lab results
• □ I authorize the discussion of my billing information

Understanding and Agreement

I understand that:

• Electronic communications are not guaranteed to be secure
• The practice will not send sensitive medical information via unencrypted email
• I can revoke this consent at any time in writing
• This consent remains valid until revoked

Signature: _________________________ Date: _____________

For Office Use Only

Received by: _______________________ Date: _____________ Entered in EMR: □ Yes □ No