Communication Authorization
Patient Name
POSA will communicate with you via the following methods:
Home telephone
Work telephone
Cellular telephone voice and text
Written communication to home address
Written communication via encrypted email
Written communication to fax number
My preferred contact (daytime) phone number
I do not wish to be communicated with via the following method(s)
or have other restrictions to include
I give permission for POSA to share tagged social media posts to our Facebook page/Google/Yelp/Health Grades or tagged with our page or location.
You may discuss my health care needs with the following individual(s), i.e. stepparent, other family members, school, neighbors, nannies, etc. (do not include physicians):
Name of Individual
Relationship to Patient
Acknowledgement of Receipt of Notice of Privacy Practices (HIPAA)
I have been offered a copy of Pediatric Orthopaedic Surgery Associates' Notice of Privacy Practices
I chose not to receive a copy of the HIPAA policy
I received a copy of the HIPAA policy (
available on our website
)
Patient or Legal Guardian 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.
Date