Consent for Contact

Please correct the errors described below.

In general, the HIPAA privacy rule gives individuals the right to request a restriction on 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 the PHI be made by alternative means, such as sending correspondence to the individual’s office instead of their home.

1. I wish to be contacted in the following manner:

First Contact Name

Relationship:

First Contact Number

cell

home

work

It is NOT ok to leave a message with details

Second Contact Name

Relationship:

Second Contact Number

cell

home

work

It is NOT ok to leave a message with details

2. Alternate contact authorization - if desired for grandparents, nanny/babysitters or patient's parents if patient is > 18 years old:

I give authorization to Oak Park Pediatrics to discuss/leave a message regarding the information below with the person listed here:

Name:

Relationship to patient:

Number

Scheduling appointments

Appointment reminders

Account information such as billing/amount due

Treatment/test results

Note: the following information will only be disclosed if specifically checked below:

Behavioral/Mental Health Information can be discussed

Drug/alcohol diagnosis, treatment and referral information can be discussed

Information about sexually transmitted diseases can be discussed

Birth control can be discussed

Pregnancy can be discussed

HIV/AIDS related health information can be discussed

3. Authorization:

Add Patient/Child Name

Parent Name (print):

Signature of parent or patient (if over 18):

Date:

4. My email address:

Your information will be encrypted.

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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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