Download - Preferred Contacts - PatientPopo OK to mail to my work/office address o Other: _____ Preferred Contacts: We respect your right to indicate who you prefer that we involve in your treatment

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Page 1: Preferred Contacts - PatientPopo OK to mail to my work/office address o Other: _____ Preferred Contacts: We respect your right to indicate who you prefer that we involve in your treatment

PriviaFinancialPolicy&NoticeofPrivacyPracticesEffective:February2018

PreferredContactsTheHIPAAPrivacyRulegivesindividualstherighttodirecthowandwheretheirhealthcareprovidercommunicateswiththem,suchassendingcorrespondencetotheindividual’sofficeinsteadoftheindividual’shome.Weinviteyoutosharewithusyourpreferredplaceandmannerofcommunication.Youmayupdateorchangethisinformationatanytime;pleasedosoinwriting.PatientName:________________________________DateofBirth:_________________

(PrintClearly)Iprefertobecontactedinthefollowingmanner(checkallthatapply):

oSendallcommunicationthroughmyPatientPortal.oHomeTelephone:___________________

oOKtoleavemessagewithdetailedinformationoLeavemessagewithcall-backnumberonly

oCellPhone:_____________________oOKtoleavemessagewithdetailedinformationoLeavemessagewithcall-backnumberonly

oWorkTelephone:____________________oOKtoleavemessagewithdetailedinformationoLeavemessagewithcall-backnumberonly

oWrittenCommunication:___________________oOKtomailtomyhomeaddressoOKtomailtomywork/officeaddress

oOther:_________________________________________PreferredContacts:Werespectyourrighttoindicatewhoyoupreferthatweinvolveinyourtreatmentorpaymentdecisionsand/orwhoweshareyourinformationwith,includinginformationaboutyourgeneralmedicalconditionanddiagnosis(suchastreatmentandpaymentoptions),accesstomedicalrecords(PHI),prescriptionpick-upandschedulingappointments.Pleasenote,however,thatwemayshareyourinformationassetforthinourNoticeofPrivacyPracticestootherpersonsasneededforyourcareortreatmentorthepaymentofserviceswehaveprovided.Pleaseupdatethisinformationpromptlyifyourpreferenceschange.Pleaseindicatetheperson(s)youpreferweshareyourinformationwithbelow:•Name:_______________________Telephone:______________Relationship:_________________•Name:_______________________Telephone:______________Relationship:_________________•Name:_______________________Telephone:______________Relationship:_________________PatientSignature:___________________________________________Date:________________

(Tobesignedbypatient’sparentorlegalguardianifpatientisaminororotherwisenotcompetent)

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