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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Patient Names and Date of Birth

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

Contacts for Patient



I authorize Lakeview Pediatrics to send electronic prescriptions to my pharmacy:

Pharmacy Information
Parent Signature