TRP PATIENT HIPAA FORM CUROGRAM

I authorize Texas Regional Physicians, its assignees and third-party collection agents to use the contact information I have provided to communicate with me and to place calls to my home/cellular/employment telephone, leave voice or text messages and use pre-recorded/artificial/voice/text messages and/or auto-dialing devices in connection with any communication to me.

Furthermore, I authorize Texas Regional Physicians to discuss my/the patient's care with the following persons:

Rows	Name	Date of Birth (or ID)	Relationship to Patient	Phone #
Person 1
Person 2
Person 3
Person 4

PRIMARY PHONE #

Format: (000) 000-0000.

SECONDARY PHONE #

Format: (000) 000-0000.

First Name

Last Name

PATIENT EMAIL

example@example.com

PATIENT DATE OF BIRTH

Date

TODAYS DATE

Date

PATIENTGUARANTOR SIGNATURE

HIPAA AUTHORIZATION AND NOTICE OF RECEIPT OF PRIVACY PRACTICES