Consent to Change Personal Health Information Preference Consents Previously Signed.

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Consent to Change Personal Health Information Preference Consents Previously Signed.
The use of this form allows you to opt out of the following previously consented to.
Use this form if you want to change your previous decision and opt out of the following (check all that apply)

TelemedicineElectronic Health Exchange opt out entirelyElectronic Health Exchange opt out of Sensitive PHI information relating to any treatment that I may have received foralcohol or drug treatment.
To Submit Your Updated Preference
Patient
Patient Signature

Clear
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Patient Name
Parent or Guardian

If patient is a minor.
Parent or Guardian Signature

Clear
Date

MonthDayYear
Date
Parent or Guardian Name
For Healow/Patient Portal, Text Messages, and marketing surveys, please follow the instructions listed to opt out of receiving notifications through those direct platforms. If you have any questions please contact DOCS Medical Inc. Administration Directors at 203-874-3682 or by e-mailing contact@DOCSofct.com
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To Submit Your Updated Preference