Confidential Communication Preference - John Muir Health printable pdf download

Date: ___________________

Patient Name: _________________________________________ Date of Birth: ________________

Parent/Legal Guardian Name for Minor Patients: __________________________________________

Our current Notice of Privacy Practices allows us to call you with a courtesy reminder regarding

upcoming appointments. In some cases it may become necessary to contact you by telephone to

discuss other medical information. In the event that you are unavailable, we would like to be able to

leave you a detailed message (e.g., lab results, x-rays, and other test results).

Please read the following choices and tell us whether or not we can leave a detailed message

(e.g., lab results, x-rays, and other test results) on an answering machine and/or with any

speciﬁ c individuals you designate below.

Choose one of the following:

I consent and authorize John Muir Physician Network and their staff to leave a detailed telephone

message regarding my medical care or my minor child at the following numbers (initial each phone

number provided).

Call in this order:

Home:

____________________________

1st 2nd 3rd choice Initials: ______

Cell Phone:

____________________________

1st 2nd 3rd choice Initials: ______

Work/Other Phone: ____________________________

1st 2nd 3rd choice Initials: ______

Minor’s Phone (patients between 12 and 17): ___________________________

Initials: ______

We take patient privacy laws very seriously, and the State of California limits what types of health

information we can share with parents about their teen. For this reason, we will maintain an exclusive

phone number for teens between the ages of 12 and 17.

I consent and authorize John Muir Physician Network to disclose verbally any results or

instructions to the following speciﬁ ed person(s) who are at least 18 years or older and may answer

the above phone number(s) in my absence:

Designee: _____________________ Relationship: ________________Phone: ________________

I do not consent or authorize detailed messages regarding my medical care to be left on

voicemail, my answering machine or with a designated person. I wish to be contacted personally.

I understand that there may be delays in receiving my results.

This communication preference will remain in effect until you rescind or provide a change.

Signature _____________________________________________ Date _______________________

3197020B (11/20/15)

PATIENT LABEL

H E A L T H

CONFIDENTIAL COMMUNICATION

PREFERENCE

Confidential Communication Preference - John Muir Health