REQUEST FOR CONFIDENTIAL COMMUNICATION
Method of Communication
I,
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:
Email
Phone
Fax
Email Address
Triangle ENT and Allergy may contact me by phone at
and/or
Triangle ENT and Allergy may leave messages on your answering machine
Yes
No
*Please note we will leave messages regarding your appointments.
Triangle ENT and Allergy may contact me by fax at
Authorizations
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 1
Contact 2
Contact 3
Contact Name 1
Contact Relationship
Contact Phone
Contact Name 2
Contact Relationship
Contact Phone
Contact Name 3
Contact Relationship
Contact Phone
Agreement and Submission
I understand that the Notice of Privacy Practices is available on the practice website and at my physician’s office. I acknowledge receipt of Triangle ENT and Allergy’s privacy policy. A paper copy is available upon request. This request may be changed or revoked by filing a new request or revoking this one in writing.
Patient Signature
– 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
Date Signed