Patient Contact Preferences

Please correct the errors described below.

In general, the H1PAA privacy rule gives individuals the right to request a restriction of uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual's office instead of the individual's home.

I wish to be contacted in the following manner (check all that apply)

Home Telephone

OK to leave message with detailed information Leave message with call-back number only

Work Telephone

OK to leave message with detailed information Leave message with call-back number only

Cell Phone

OK to leave message with detailed information Leave message with call-back number only OK to text appointment information

Written Communication

OK to mail to my home address OK to mail to my work/office address OK to email detailed treatment information and appointment information OK to fax detailed treatment information to this number

Work/Office Address

Email Address

Fax Number

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.

Patient Signature /Guardian

Date

Name

Birth Date

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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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