Healthcare DENC Form

Healthcare DENC Form

Patient Information

Patient Name:

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History (Brief)

Authorization for Electronic Communications (DENC)

Provider Name:

Purpose of Electronic Communications:

I authorize the Provider identified above to communicate with me using the following electronic methods (check all that apply):

Email (send to):

SMS/Text (send to):

Automated/Live Phone Calls:

Leave Voicemail Messages at above phone numbers

Secure Patient Portal Messages

Scope of Protected Health Information (PHI)

The types of PHI that may be transmitted electronically under this authorization include (check all that apply):

Appointment reminders and scheduling information

Routine test results (non-sensitive)

Treatment information and instructions

Billing, insurance and payment communications

Other (specify):

Risks, Benefits, and Patient Responsibilities

Risks: I understand that electronic communication (including email, SMS, and voicemail) may be intercepted by third parties or delivered to an unintended recipient. The Provider cannot guarantee the security or confidentiality of electronic communications. I accept these risks and consent to the use of the selected electronic methods.

Benefits: Electronic communications may improve access to care, timeliness of results, and efficiency of scheduling and billing.

Patient Responsibilities: I agree to keep contact information current, inform the Provider promptly of any change to my email address or phone number, and understand that I remain responsible for follow-up care and for reviewing any electronic communications received.

Duration, Revocation, and Expiration

This authorization is valid until: . If no date is provided, this authorization expires one year from the date signed.

I understand I may revoke this authorization at any time by providing written notice to the Provider named on this form. Revocation will not affect communications already sent or actions already taken in reliance on this authorization prior to receipt of the revocation.

HIPAA Acknowledgment

I acknowledge that I have been offered or provided with the Provider's Notice of Privacy Practices describing how my protected health information may be used and disclosed, and my rights under privacy law.

Certification

By signing below I certify that I am the patient named above or the patient's legally authorized representative. I have read and understand the terms of this Digital Electronic Notification Consent (DENC) and authorize the Provider to communicate with me electronically as indicated.

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