Communicating with You

To effectively communicate with you about your medical and financial needs, 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, financial information or respond to a message you left for your physician’s office. We may communicate with you through mail, secure email (Secure Patient Portal), and telephone, including text messages, 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:

Cell

Home

Work

You may leave a message/voice mail

Phone Number:

Cell

Home

Work

You may contact me through email (Secure Patient Portal)

You may contact me through secure texting

Cell Phone Number:

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 psychiatric services and/or HIV test results.

Add New Information

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

The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov

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:

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

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.