New Patient Health History Form (Page 7 of 7) in pdf

Patient-Provider Contact Agr eement

Federal law now requires very strict limitations on the manner in which providers can contact their patients in order to

maintain confidentiality. Although the theory is a good one, it can make life complicated for all of us. We would

therefore like to ask you now for permission to contact you in the best way for your lifestyle. Listed below are several

options; please mark the ones you agree to. You may change these at any time by contacting us in writing.

Phone cont act:

Preferred number to use: Home ___ Work ___ Cell____ (please check one)

Home phone:

You may not leave messages on my machine about lab and test results, but you may leave appt reminders. ______

You may leave any kind of message on my machine, including lab and test results. _______

You may not leave messages with family members. _____

You may leave messages with family members. ______

I do not have an answering machine. ______

Wor k phone:

You may not leave messages concerning lab and test results, but you may leave appt reminders. ______

You may leave messages on my voicemail, including lab and test results. _____

You can not contact me at my work. ______

Not applicable to me. ________

Cell phone:

You may not leave messages on my voicemail about lab and test results, but you may leave appt reminders. ____

You may leave any kind of message on my voicemail, including lab and test results. ____

I do not have access to voicemail on my cell phone. ____

Email Agr eement

Email is an easy and convenient way for us to communicate. For instance, it allows you to contact us during a time

we are not open. However, please remember that it does have drawbacks. For instance, not all providers are in the

office each day and you won’t know if we are on vacation. We will make every effort to check email frequently, but i t

coul d be sev er al day s bef or e you hear f rom us. Email is nev er , ev er appropriate for emergencies or

urgent questions. It is also not appropriate for any questions that require a good deal of discussion; it is not a

substitute for an office visit. Email does not know how to do exams---if you think you need to be seen, please call to

make an appointment. Also remember that email is not confidential; our system has no additional security beyond

your usual email provider’s system. You therefore may not want to discuss some sensitive issues via email. Any

emails to our office become a part of your medical record.

Guidelines for use: Please send your message to the appropriate provider (eg. ).

If you aren’t sure or you need to contact the front desk, please send your message to .

I do want to use email to communicate with this office. _____

I do not want to use email to communicate with this office. ____

Your Signature: _________________________________ Today’s Date: ________________________________

940 Town Center Drive, Suite F-90

Langhorne, PA 19047

Phone: 215.741.1600/Fax: 215.741.1601

New Patient Health History Form Page 7