Confidential Communication Request (HIPPA Form)

Please correct the errors described below.

PATIENT

In order to protect your child’s privacy, we need your written permission to leave detailed phone,
email or text messages regarding your child, including messages that contain health and/or billing
information. Please note that current Notice of Privacy Practices allows us to contact you without
written approval with a courtesy reminder regarding upcoming appointments.

PLEASE INDICATE YOUR AGREEMENT BY MARKING ALL THAT APPLY. LEAVE BLANK ANY FOR WHICH YOU DO NOT GIVE CONSENT.

THE ABOVE PERMISSION WILL REMAIN IN EFFECT UNTIL RESCINDED IN WRITING.

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

Your information will be encrypted.

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