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Consent for Contact

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI may be made by alternative means, such as sending correspondence to the individual’s office instead of their home.

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1. I wish to be contacted in the following manner (check all that apply):

Contacts for Patient
First Contact Name:		Relationship?:
First Contact Number:		Type:	Cell Home Work
	It is NOT ok to leave a message with details:

Second Contact Name:		Relationship?:
Second Contact Number:		Type:	Cell Home Work
	It is NOT ok to leave a message with details:

Contacts for Patient
Third Contact Name:		Relationship:
Third Contact Number:		Type:	Cell Home Work
	It is NOT ok to leave a message with details:

2. Appointment reminder preference (choose ONE):

	Text:	To Number:

	Call:	To Number:

	Email:	To Email Address:

3. Alternate contact authorization - if desired for grandparents, nanny/babysitters or patient's parents if patient is > 18 yo:

I give authorization for Lakeview Pediatrics to discuss/leave a message regarding the information below with the person listed here:


Name:			Relationship to Patient:

Number:

I give permission to leave a message at this number:

Scheduling appointments
Appointment reminders
Account information such as billing/amount due
Treatment/test results

Note: the following information will only be disclosed if specifically checked below:

Behavioral/Mental Health Information can be discussed
Drug/alcohol diagnosis, treatment and referral information can be discussed
Information about sexually transmitted diseases can be discussed
Birth control can be discussed
Pregnancy can be discussed
HIV/AIDS related health information can be discussed

4. Authorization

Patient Names and Date of Birth
Patient Name:*			DOB:*
Patient Name:			DOB:
Patient Name:			DOB:
Patient Name:			DOB:

Parent Name:

Parent Signature:

Today’s Date:

My email address:

Security code:

Enter security code: