Pediatric Practice Communication Consent Form

Patient Information

Child's Name: _________________________ Date of Birth: ______________ Parent/Guardian Name: __________________ Relationship: ______________

Communication Preferences

I authorize [Practice Name] to communicate with me about my child's protected health information via the following 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

Authorized Recipients

I authorize the following individuals to receive information about my child's care:

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

Acknowledgment

• I understand that email and text messaging are not confidential methods of communication
• I acknowledge that messages may include my child's personal health information
• I understand I can revoke this consent at any time in writing
• This consent remains valid until revoked or updated

Signature: _________________________ Date: ______________

This form complies with HIPAA requirements and medical privacy regulations