REQUEST FOR CONFIDENTIAL COMMUNICATION
Method of Communication
hereby request Triangle ENT and Allergy to keep communications regarding my protected health information confidential. To accomplish this request please adhere to the following requests:
Preferred Contact Format:
Triangle ENT and Allergy may contact me by phone at
Triangle ENT and Allergy may leave messages on your answering machine
*Please note we will leave messages regarding your appointments.
Triangle ENT and Allergy may contact me by fax at
I give authorization to the doctors and staff of Triangle ENT and Allergy to discuss any of my medical and/or financial information with the following people:
Contact Name 1
Contact Name 2
Contact Name 3
Agreement and Submission
– Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Patient Name – printed
Date of Birth