Patient Communication Consent Form - Oncology

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record #: ________________

Authorization for Communication

I, _________________________________, authorize [Practice Name] to communicate my medical information in the following ways:

Approved Communication Methods

• Phone Call - Primary: ________________
• Phone Call - Secondary: ______________
• Voicemail Messages
• Text Messages
• Email: ____________________________
• Patient Portal

Approved Information Types

• Test Results
• Appointment Reminders
• Treatment Plans
• Medication Instructions
• Billing Information

Authorized Representatives

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

1. Name: ___________________ Relationship: ____________ Phone: __________________ Information Type: [ ] All [ ] Limited

2. Name: ___________________ Relationship: ____________ Phone: __________________ Information Type: [ ] All [ ] Limited

Special Instructions

Understanding and Agreement

• I understand this authorization remains valid until revoked in writing
• I understand I can modify or revoke this consent at any time
• I acknowledge that electronic communications may not be secure
• I accept the risks of communication via my chosen methods

Patient Signature: _________________ Date: ____________

Witness Signature: _________________ Date: ____________