Healthcare Outreach Letter

HEALTHCARE OUTREACH LETTER

Date:

Sender Identification

Patient Information

Date of Birth:    Gender:

Primary Phone:    Email:

Insurance Information

Medical History (Summary)

Outreach Purpose and Proposed Actions

Purpose of outreach: The clinic is contacting the patient regarding

Proposed contact start date:    Frequency:

Contact Preferences and Permissions

Please indicate preferred methods of contact (check all that apply):

Phone call Text message (SMS) Email Postal mail

Permission to leave voice messages at the primary phone: Yes    Permission to send SMS/text messages: Yes

Authorized Representative

I authorize the following individual to receive outreach communications on my behalf:

Consent and Privacy Acknowledgment

By signing below, I authorize the clinic to contact me and/or my authorized representative using the methods indicated above for the stated purpose(s). Outreach communications may include appointment reminders, health reminders, care coordination, referrals, and limited billing or insurance-related messages. Messages may be delivered via live calls, recorded messages, automated telephonic systems, text messages (SMS), and email as appropriate to the contact method selected.

I understand that although the clinic will take reasonable measures to protect my health information, electronic communications (including email and text) may not be encrypted. The clinic will limit disclosures to the minimum necessary to accomplish the outreach purpose and will comply with applicable privacy laws. I may revoke this consent at any time by notifying the clinic; revocation will not affect disclosures made prior to receipt of the revocation.

Participation in outreach is voluntary and does not change my right to receive care. Refusal to consent to outreach will not affect my access to treatment or services, except to the extent outreach is a component of a specific program for which participation is required.

I hereby indicate my preferences and consent below:

I consent to receive outreach communications as described above.

I authorize the clinic to share the minimum necessary health information with care coordination staff and authorized representatives for outreach purposes.

Acknowledgment

I acknowledge that I have read and understand the information in this Healthcare Outreach Letter. I certify that the information provided on this form is true and complete to the best of my knowledge. I understand I may withdraw consent at any time and that my withdrawal will not affect disclosures made in reliance on this authorization prior to receipt of the withdrawal.

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