You may elect to have your PHI provided to you by signing this form in the space provided below. You may message us as a request to receive your PHI. Once you have signed this form, future communication with you concerning your PHI via phone call, text or email may be provided to you and also to the designated relative or friend on a voice mail at the number you provide to this office.
Please note that PHI cannot be provided to any personal relative (mother, father, siblings, spouse, etc.) without your consent and written signature (eSignature).
I understand my HIPAA rights and I request that this office leave messages, including those containing PHI, for me with the individual(s) listed below at the numbers noted below. I understand that it is my responsibility to keep the practice informed of any changes to this information.