Communication Consent Form printable pdf download

Chart #: ______________

Communication Consent Form

In order to comply with HIPAA (Health Insurance Portability and Accountability Act of 1996)

regulations, we ask that our clients review and sign this Communication Consent Form.

Preferred EAP will not release confidential and/or other Protected Health Information (PHI) by

home mailing, home telephone, answering machine, work telephone, voice mail, cell phone and/or

pager. When we place telephone calls and an answering machine responds, we do not leave a

message if the name or telephone number is not on the recorded message to identify the

residence. Information will also not be left with an unauthorized person who may answer the

telephone.

I, _____________________________________ authorize Preferred EAP to contact me and/or

named authorized person(s) and to convey PHI by the following methods and assume responsibility

to notify Preferred EAP whenever this information changes:

Email: _____________________@___________________

• ____Yes ____No For EAP Satisfaction Survey ONLY

• ____Yes ____No For other treatment-related purposes

Home Mail

____Yes

____No

Home Telephone

____Yes

# ________________ ____No

Answering Machine

____Yes

# ________________ ____No

Work Telephone

____Yes

# ________________ ____No

Voice Mail

____Yes

# ________________ ____No

Cell Phone

____Yes

# ________________ ____No

Pager

____Yes

# ________________ ____No

Fax PHI

____Yes

# ________________ ____No

Who may we contact in case of an emergency?

Name: _______________________________

Relationship: _______________

Phone Numbers: _________________________ __________________________

Please list names of other people authorized to receive information about your care:

Spouse: ______________________________________

Parent: _______________________________________

Other: _______________________________________

Client Signature: __________________________________________

Date: _______________

Parent/Guardian Signature

: __________________________________ Date: _______________

)

(Needed if child is less than 14 years of age)

EAP Witness Name: _______________________________________________________________

EAP Witness Signature: ______________________________________ Date: ________________

A copy of this document will be provided to you upon request.

Communication Consent Form

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