• Patient Communication Preference Regarding PHI

  • Telephone Communication Preferences

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  • Email Communication Preferences

  • 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.

  • 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.

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