Hipaa Patient Calling Information Form

Please correct the errors described below.

With whom do you allow us to share your medical Information?

Add new information

How may we contact you?
Please list in the order the way you wish to be contacted. (1-3)

If you like to communicate with our office via email, we encourage you to sign up for MyCare. This is a secure web portal. You can do this by going to www.stfranciscare.org/mycare . There is also an app on Googleplay or the App Store called My Chart.

**I understand that it is my responsibility to notify the office of any changes in my calling or HIPAA communication information.

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

Your information will be encrypted.