Patient Communication Authorization Form

Patient Information

Name: ___________________________ Date of Birth: _______________ Medical Record #: _________________ Date: _____________________

Authorized Communication Methods

I hereby authorize [Practice Name] to communicate with me using the following methods (check all that apply):

• Cell Phone: _________________
  • Voice Messages
  • Text Messages
• Home Phone: ________________
  • Voice Messages
  • Detailed Messages
• Work Phone: ________________
  • Voice Messages
  • Detailed Messages
• Email: ____________________
• Patient Portal

Authorized Recipients

I authorize the release of my medical information to the following individuals:

1. Name: _________________ Relationship: _____________ Phone: _____________
2. Name: _________________ Relationship: _____________ Phone: _____________

Communication Content Authorization

I authorize communication regarding (check all that apply):

• Appointment reminders
• Test results
• Medication information
• Surgery scheduling
• Billing information
• Medical advice/instructions

Understanding and Agreement

• I understand that email and text messaging are not secure forms of communication
• I acknowledge that messages may contain personal health information
• I accept the risks associated with these communication methods
• I understand I can modify or revoke this consent at any time in writing

Signature: _________________________ Date: _________________

For Office Use Only

Received by: _______________________ Date: _________________ Entered in EMR: [ ] Yes [ ] No