Patient Preference for Disclosure of Personal Medical Information

Name*

First Last

The HIPAA privacy law gives individuals the right to request restriction on users and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that communication of PHI be made by alternative means.
Please read and mark those forms of communication listed below that you personally approve for disclosure and discussion of protected health information. Please put a checkmark on all the contact boxes with your preferences.

Communication with person(s) other than the patient: Is there a power of attorney?*

Yes
No

Please upload a copy of the power of attorney*

Accepted file types: pdf, doc, docx, Max. file size: 256 MB.

May we discuss your condition with anybody else?*

Yes
No

Please list the name(s) and relationship(s) to you.*

Name	Relationship	Phone

Patient Contact Information

Home Phone Number*

May we leave a message about your appointment?*

Yes
No

May we leave a message about your condition?*

Yes
No

Cell Phone Number*

May we leave a message about your appointment?*

Yes
No

May we leave a message about your condition?*

Yes
No

Is there an additional number you wish to use?*

Yes
No

Additional Phone Number

May we leave a message about your appointment?

Yes
No

May we leave a message about your condition?

Yes
No

*If you would like your medical information to be faxed to you when requested in the future, please provide us your fax number. If no fax number is provided, then you’ll have to sign a separate release form in the future in order for us to send your medical information to you via fax.

Unless otherwise revoked, or an alternative expiration date is provided here, this authorization is valid for ONE YEAR from the date listed below. Initials:

I grant permission to Raffi Tachdjan, MD to relay, leave message, and fax me with detailed information regarding my personal health information with the person(s) and contact number(s) and information listed above.

Enter Patient (or parent) Name*

Signature*