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.
UrbanCare, LLC may contact me by phone at:
UrbanCare, LLC may leave messages on your answering machine
Please note we will leave messages regarding your appointments.
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:
I understand that the Notice of Privacy Practices is
This request may be changed or revoked by filing a new request or revoking this one in writing.
– 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 of Birth
If you are not the patient, please specify your relationship to the patient