HIPAA Privacy Communication Authorization Form

HIPAA Privacy Communication Authorization Form

Purpose of this section: I give permission to the employees of Waggoner Pediatrics of Central Iowa to contact me and leave me messages as they relate to the medical care of myself, my child, or my children at Waggoner Pediatrics of Central Iowa.
Patient Name:*

First NameMiddle NameLast Name
Patient Date of Birth*

MonthDayYear
Date

Primary Contact Info
Name*

First NameLast Name
Relationship to Patient*
Phone Number*
Please enter a valid phone number.
Do you allow Waggoner Pediatrics of Central Iowa to leave a message at this number?*

YesNo

Health Insurance Portability and Accountability Act of 1996 (HIPAA)
I authorize the disclosure of patient indvidual health information when necessary, including but not limited to when required by law, when working with laboratories and testing facilities, and for billing purposes. For complete HIPAA disclosures and conditions and use information, please contact the billing office.
HIPAA Signature

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

Primary Contact Info