Healthcare Communication Preferences

Healthcare Communication Preferences

This form documents the patient’s preferences and authorizations for the methods and content of communications from the health care provider. By completing and signing this form the patient or authorized representative grants permission for the provider to communicate protected health information (PHI) in the manner(s) and for the purposes indicated below, subject to the terms and limitations stated herein.

Patient Information

Insurance Information

Emergency Contact

Communication Methods — Authorizations

Indicate all methods by which the provider may contact you and whether messages may include protected health information. If a method is not selected, the provider will not use that method to communicate PHI.

Home phone    Cell phone    Work phone    SMS / Text message    Email    Postal mail    Secure patient portal

Do NOT leave voicemail or other messages containing PHI on any phone or device

May leave detailed voicemail messages that include health information

Types of Information Authorized

Select the categories of information the provider is permitted to transmit via the selected methods.

Appointment reminders & scheduling notifications
Billing, insurance, and payment information
Laboratory and diagnostic test results
Prescription refill notifications and reminders
Treatment and care coordination information
Sensitive information (e.g., mental health, substance use, HIV) — send only via secure patient portal or in-person unless specifically authorized below

If you checked sensitive information to be sent via less secure methods, specify methods you expressly authorize:

Security, Risks, and Acknowledgment

I understand that communications sent by unencrypted email, SMS, or voicemail may be intercepted or accessed by third parties. The provider will use reasonable safeguards to protect my PHI when using electronic communications, but cannot guarantee confidentiality of unencrypted messages. I acknowledge these risks and accept them for the selected communication methods.

I authorize the provider to transmit my PHI by the selected methods and for the selected purposes. I release the provider from liability for unauthorized access to my PHI transmitted by the selected non-secure methods, provided the provider has taken reasonable safeguards as required by applicable law.

Authorized Persons

List any persons (other than the patient) who are permitted to receive your health information and the types of information they may receive. The provider may require proof of identity before releasing information to an authorized person.

Duration and Revocation

This authorization will remain in effect until the earlier of: (a) the expiration date entered below, or (b) the date the provider receives written notice of revocation from the patient or authorized representative. Revocation will not apply to disclosures already made in reliance on this authorization prior to receipt of the revocation.

Limitations and Special Instructions

Certification and Signature

By signing below I certify that I am the patient named on this form, or that I am the duly authorized representative of the patient with authority to execute this authorization. I have read and understand the terms of this Healthcare Communication Preferences form. I understand I may revoke this authorization in writing at any time, except to the extent the provider has already acted in reliance on it.

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