Communicating with You

To effectively communicate with you about your medical information we request that you complete this form identifying the best ways to provide you with your confidential information. We may need to communicate test results, prescription information or respond to a message you left for your physician’s office. We may communicate with you through mail, secure email (NextMD Patient Portal), and telephone, including leaving messages on your answering machine’s/voice mail.

Please check all boxes that give Pediatric and Adolescent Medicine permission to use for your communications:

You may contact me by telephone

Phone Number:

Message OK

Cell

Home

Work

Add new contact information

Please list any persons you would like to have access to your billing, appointment or health information, such as your spouse, caretaker or other family member. We will ask for additional consent prior to releasing information related to Behavior Health and/or HIV test results.

Name:

Phone Number:

Relationship:

Options

Billing Information

Appointment Information

Medical/Health Information

Add New Information

This request supersedes any prior request for communication of information I may have made.

Acknowledgement of Receipt of Notice of Privacy Practices

I hereby acknowledge that I received a copy of the notice of Privacy Practices for the above medical practice. I further acknowledge that a copy of the current notice is posted in the reception area and that any amended notice of Privacy Practices will be made available at my next appointment.

If not signed by the patient, please indicate:

Relationship:

Parent or guardian of minor patient Legal Guardian or conservator of an incapacitated patient Beneficiary or personal representative of deceased patient

Name of Patient, if patient NOT signing:

Signature of Patient/Responsible Party

Patient Date of Birth

Todays Date

Name of Patient/Responsible Party (Print)

Relationship to Patient

Your information will be encrypted.