Family And Friends Contact Form

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FAMILY AND FRIENDS CONTACT FORM
Persons who are involved in your care (family, friends, other doctors, etc.) may inquire about your
treatment, lab results, prescriptions, etc. Please let us know what persons we may share
information with. (Please note: In emergency situations or other situations outlined in our Notice of
Privacy Practice we may share information with others who are not specifically listed on this form.)
Please list those persons (including Family, Friends, Previous Treating Physicians, your Family
Doctor (PCP), and other doctors/specialists) with whom we may share your information:
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What is the best phone number for us to contact you?
Phone Number: _______________________________________________________________________
What is this number (Home, Work, Cell, Other)? ______________________________________________
From time to time we will leave a message for you (as stated in our Notice of Privacy Practices) on an
answering machine, voice mail, or with another individual in your absence. Is it OK for such message to
include details (such as diagnosis and medication information) at this number? _________________
What other ways may we contact you? Please list any that are acceptable ways to reach you.
Home Phone Number: _________________________________________________________________
Is it OK to leave a detailed message at this number in your absence? _____________________________
Work Number: ________________________________________________________________________
Is it OK to leave a detailed message at this number in your absence? _____________________________
Cell Phone Number: ___________________________________________________________________
Is it OK to leave a detailed message at this number in your absence? _____________________________
Other: _______________________________________________________________________________
Is it OK to leave a detailed message at this number in your absence? _____________________________
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Signature of Patient or Legal Representative
Date
_______________________________________________
___________________________
Print name of Patient or Legal Representative
Relationship to Patient

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