R
equest for
C
onfidential
C
ommunication
I,
*
hereby request UrbanCare, LLC to keep communications regarding my protected health information confidential. To accomplish this request please adhere to the following requests.
Our preferred method of communication is through our secure patient portal. Providing your email address allows us to invite you to join our portal.
Email
Phone
*
UrbanCare, LLC may contact me by phone at:
Home
and/or Cell
UrbanCare, LLC may leave messages on your answering machine
*
Yes
No
Please note we will leave messages regarding your appointments.
Fax
UrbanCare, LLC may contact me via FAX at
I give authorization to the doctors and staff of UrbanCare, LLC to discuss any of my medical and/or financial information with the following people:
Name
Relationship
Phone
Add another?
Add another?
I understand that the Notice of Privacy Practices is
available here
and at my physician’s office. I acknowledge receipt of UrbanCare, LLC privacy policy. A paper copy is available upon request. In addition, I authorize UrbanCare, LLC to register me in I-Care (Illinois Comprehensive Automated Immunization Registry Exchange). I acknowledge that Urbancare will send my immunizations to the Illinois Comprehensive Automated Immunization Registry Exchange unless I opt out (see Receptionist for Opt Out Form).
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
*
Date of Birth
*
If you are not the patient, please specify your relationship to the patient
Date
*