Communication Preference Form

1
Client Name* This field is required.
First Name
Last Name
2
Date* This field is required.
Date
Month
Day
Year
3
In an effort to ensure your privacy, it is important for us to understand your preferred method of receiving and communicating medical and administrative information pertaining to your therapy. As such, please indicate your communication preferences below.
4
Written Documentation and Verbal Information:
I grant permission to provide me with written communication via HIPAA compliant encrypted email service via my email provided.
I grant permission to provide me with written communication (such as appointment reminders or cancellations) via text message. I understand that with this option, written communication may be viewed by an unintended third party and I fully accept this risk.
I grant permission to provide me with written communication via USPS in an unmarked envelope.
I elect to receive clinical information in person or via telephone through the number provided.
I grant permission to leave relevant medical information on my voicemail. I also give permission to release medical information pertaining to the client to the individuals listed in the next slide:
5
Sharing of Information (if applicable)
Pediatrician or Doctor's Name
Practice Number
Email Address and/or Phone Number
Pediatrician or Doctor's Name
Practice Number
Email Address and/or Phone Number
6
Sharing of Information cont. (if applicable)
Individual's Name
Relationship to Client
Email Address and/or Phone Number
Individual's Name
Relationship to Client
Email Address and/or Phone Number
7
By completing this form, I understand that it is my responsibility to inform the practice of changes to my preferred contact information or my communication preferences, as well as, to revoke this authorization at any time.
8
Signature of Client or Legal Representative* This field is required.
Clear
9
If Legal Representative, please describe relationship to client:
10
Please verify that you are human* This field is required.
Should be Empty: