Confidential Communication Request (HIPPA Form)

Please correct the errors described below.

Date

PATIENT

Patient's Last Name

First Name

Middle Initial

Birth Date

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.

Detailed phone messages regarding my child may be left on the following numbers:

Phone

Initials

Phone

Initials

Detailed text messages regarding my child may be sent to the following numbers:

Phone

Initials

Phone

Initials

Detailed emails regarding my child may be sent to the following email address.

Initials

I give permission for Julie Tomberlin MD PA to give detailed information regarding my child to the following:

Name

Relationship

Phone

Name

Relationship

Phone

THE ABOVE PERMISSION WILL REMAIN IN EFFECT UNTIL RESCINDED IN WRITING.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

Signature

Printed Name

Your information will be encrypted.

Electronic signature

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I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

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