preferred contacts - patientpopo ok to mail to my work/office address o other: _____ preferred...

PriviaFinancialPolicy&NoticeofPrivacyPracticesEffective:February2018

PreferredContactsTheHIPAAPrivacyRulegivesindividualstherighttodirecthowandwheretheirhealthcareprovidercommunicateswiththem,suchassendingcorrespondencetotheindividual’sofficeinsteadoftheindividual’shome.Weinviteyoutosharewithusyourpreferredplaceandmannerofcommunication.Youmayupdateorchangethisinformationatanytime;pleasedosoinwriting.PatientName:________________________________DateofBirth:_________________

(PrintClearly)Iprefertobecontactedinthefollowingmanner(checkallthatapply):

oSendallcommunicationthroughmyPatientPortal.oHomeTelephone:___________________

oOKtoleavemessagewithdetailedinformationoLeavemessagewithcall-backnumberonly

oCellPhone:_____________________oOKtoleavemessagewithdetailedinformationoLeavemessagewithcall-backnumberonly

oWorkTelephone:____________________oOKtoleavemessagewithdetailedinformationoLeavemessagewithcall-backnumberonly

oWrittenCommunication:___________________oOKtomailtomyhomeaddressoOKtomailtomywork/officeaddress

oOther:_________________________________________PreferredContacts:Werespectyourrighttoindicatewhoyoupreferthatweinvolveinyourtreatmentorpaymentdecisionsand/orwhoweshareyourinformationwith,includinginformationaboutyourgeneralmedicalconditionanddiagnosis(suchastreatmentandpaymentoptions),accesstomedicalrecords(PHI),prescriptionpick-upandschedulingappointments.Pleasenote,however,thatwemayshareyourinformationassetforthinourNoticeofPrivacyPracticestootherpersonsasneededforyourcareortreatmentorthepaymentofserviceswehaveprovided.Pleaseupdatethisinformationpromptlyifyourpreferenceschange.Pleaseindicatetheperson(s)youpreferweshareyourinformationwithbelow:•Name:_______________________Telephone:______________Relationship:_________________•Name:_______________________Telephone:______________Relationship:_________________•Name:_______________________Telephone:______________Relationship:_________________PatientSignature:___________________________________________Date:________________

(Tobesignedbypatient’sparentorlegalguardianifpatientisaminororotherwisenotcompetent)