Consent for Contact 18+

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:

Name:

Contact Number:

Email address

It is NOT ok to leave a message with details

2. Parent contact authorization - Now that you are over age 18, please check here to provide permission for your parent/s to contact us on your behalf and for OPP staff/ doctors to communicate with your parent/s. I give authorization to Oak Park Pediatrics to discuss/leave a message regarding the information below with the person listed here:

Parent 1:

Contact Number:

Parent 2:

Contact Number:

Check if you would like your parent to be able to:

Schedule appointments

Receive appointment reminders

Discuss 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

Signature of patient:

Date:

Your information will be encrypted.

Electronic signature

Your browser does not support capabilities required for electronic signatures.

Loading templates...

Use existing signature
Type the signature
Draw
Upload an image

Click a signature you want to use:

Clear

Drop image file here or click to select file Click here to select image file from your computer

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.

Use this signature or Cancel

Hushmail

Hide