Patient Communication Preference Regarding PHI

Patient Communication Preference Regarding PHI
Telephone Communication Preferences
Patient Name
Date

Month Day Year
Date
Physician
Home #
Work #
Mobile #
Other
Email Communication Preferences
Email
example@example.com
In order to best serve our patients and communicate regarding their services and financial obligations, we will use all methods of communication provided to expedite those needs. By providing the information above, I agree that Michael Pennachio LLC, (d/b/a Pennachio Eye) or one of its legal agents may use the telephone numbers provided to send me a text notification, call using a pre-recorded artificial voice message through the use of an automated dialing system or leave a voice message on an answering device. If an email address has been provided, Pennachio Eye or one of its legal agents may contact me with an email notification regarding my care, our services, or my financial obligation.
Other than you, your insurance company and health care providers involved in your care, whom can we talk about your health care information? (Check all that apply)

Spouse Caregiver Child Parent Other
Spouse Name & Phone
Caregiver Name & Phone
Child Name & Phone
Parent Name & Phone
Other Name & Phone
I acknowledge that I have received a copy of the Privacy Notice for Pennachio Eye. I acknowledge that I have been given the opportunity to request restrictions on use and/or disclosure of my protected health information. I acknowledge that I have been given the opportunity to request alternative means of communication of my protected health
information.
Patient or Personal Representative Signature

Clear
Date

Month Day Year
Date
Printed Name
Relationship to Patient
Should be Empty: