Patient Communication Form

Please correct the errors described below.

A. Family and Friends. It is the office policy of FDL Dermatology not to release confidential medical information regarding your treatment to family members or friends, except for (i) parent/legal guardian, (ii) other persons authorized by the patient, (iii) as we may reasonably infer from the circumstances (for example, if you bring a family member or friend into the exam room, we will assume, unless you object, that that person is entitled to receive information regarding your treatment), (iv) in emergency situations, or (v) other as otherwise permitted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

If you anticipate that you will need or want your medical information to be provided to family members, friends, or caretakers/babysitters, please indicate that below, so that we may best serve you. If you do not want any of your medical information provided to a family member, please check the line next to the "no" response. By signing below, you authorize the following people to receive information regarding your treatment or care. (If you wish to add names later on, please confirm this in writing, or call our staff.)

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B. Alternative Communications. You are also entitled to specify alternative, reasonable means of communication, if you do not wish to be contacted in a certain way.

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

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