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.
Printer Friendly
 

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

Contacts for Patient
Type:


 
 
Type:


 

 
Contacts for Patient
Type:


 
 
2. Appointment reminder preference (choose ONE):
 
       
       
       


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

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





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







4. Authorization
Patient Names and Date of Birth
*
*
 
   
   
   
My email address: