Authorization for Communication and Release of Medical Information

Date: _____________

Patient Name: _________________________ Date of Birth: _____________

Communication Preferences

I, ______________________, authorize [Practice Name] to communicate with me and release my protected health information through the following methods:

Electronic Communications

• Email: ________________________________
• Text Messages (SMS) to: ________________
• Patient Portal

Telephone Communications

• Home Phone: __________________________
• Cell Phone: ___________________________
• Work Phone: __________________________

Voicemail Authorization

I authorize detailed messages to be left on the following numbers:

• Home Phone
• Cell Phone
• Work Phone

Authorized Representatives

I authorize the following individuals to receive information about my medical care:

1. Name: ___________________ Relationship: ____________ Phone: ____________
2. Name: ___________________ Relationship: ____________ Phone: ____________

Information Release Authorization

I authorize the release of the following types of information:

• Appointment schedules and reminders
• Pre-operative instructions
• Post-operative care instructions
• Surgical results and photographs
• Billing information
• Medical records

Understanding and Agreement

I understand that:

• This authorization is valid until revoked in writing
• Communication through email and text is not encrypted and may pose security risks
• I may revoke or modify this authorization at any time by notifying the practice in writing
• The practice will make reasonable efforts to comply with my communication preferences

Patient/Guardian Signature: _________________ Date: _____________

Witness Signature: ________________________ Date: _____________