Physical Therapy Communication Authorization Form

I, _________________________ (print patient name), authorize [PRACTICE NAME] to communicate regarding my protected health information through the following methods:

Contact Authorization

Phone Communication

• Home Phone: (____) ____ - ______

  • Leave detailed messages
  • Leave call-back requests only

• Mobile Phone: (____) ____ - ______

  • Leave detailed messages
  • Leave call-back requests only
  • Send appointment reminders via text

• Work Phone: (____) ____ - ______

  • Leave detailed messages
  • Leave call-back requests only

Electronic Communication

• Email: ________________________
  • Send appointment reminders
  • Send exercise instructions
  • Send billing information

Authorized Individuals

I authorize the following individuals to receive information about my physical therapy care:

1. Name: ________________________ Relationship: ________________ Phone: (____) ____ - ______ Information type: [ ] All [ ] Limited

2. Name: ________________________ Relationship: ________________ Phone: (____) ____ - ______ Information type: [ ] All [ ] Limited

Understanding & Agreement

• I understand this authorization remains valid until revoked in writing
• I may modify or revoke this authorization at any time by notifying the practice in writing
• This authorization is voluntary

Patient/Guardian Signature: ________________________ Date: //____

Print Name: ________________________ Relationship to Patient: ________________