Lvpg Medical Information Communication Preferences printable pdf download

Lvpg Medical Information Communication Preferences

LVPG Medical Information Communication Preferences

Patient __________________________________ MR#_________________________ DOB ____/___/____

As our patient, we may need to communicate with you when you are not in the practice. To assure your

privacy, we would like you to indicate your preferred method for us to communicate medical information to you

and/or to others involved in your care. Please note that an “appointment reminder” is not classified as medical

information.

PLEASE INDICATE YOUR COMMUNICATION PREFERENCES BELOW:

I give permission to leave medical information pertaining to me, my dependent or child, at the

numbers listed below:

Method

Yes

Area Code, Phone #, Extension

Home

Answering Machine

Work Phone

Cell Phone

Pager

Without specific permission, we will not release any medical information to anyone other than you. In some

cases you may wish for another person to have access to your medical information. Please identify those

individuals and their relationship to you (i.e. spouse, parent, son, daughter, partner etc.):

Do not release medical information to anyone other than myself.

I give permission to release medical information pertaining to me to the individuals listed below.

Relationship (i.e. spouse, parent,

Name

son, daughter, etc.)

Area Code, Phone # - Extension

Comments

I assume responsibility to inform the practice of changes in my phone number(s) or my preferences or to

revoke this specific medical information authorization at any time.

___________________________________________________

______________________

Signature

Date

___________________________________________________(Please Print Name)

X:\LVPG Admin\Forms\LVPG Pt Communication rev 05.2009.doc

Lvpg Medical Information Communication Preferences