HIPPA Alternative Contact Waiver

First Name:

Please complete this field.

Middle Initial:

Please complete this field.

Last Name:

Please complete this field.

Date of Birth:

Please complete this field.

Street Address:

Please complete this field.

City:

Please complete this field.

State:

Please complete this field.

Zip:

Please complete this field.

Home Phone:

Please complete this field.

Cell Phone:

Please complete this field.

In Case of Emergency, please notify:

Name:

Please complete this field.

Relationship:

Please complete this field.

Phone:

Please complete this field.

Federal regulations developed under the Health Insurance Portability and Accountability Act (HIPAA) requires our practice make you aware we are unable to contact you directly by internet or through e-mails or faxes or other electronic transmission sources without your expressed written consent and waiver of any responsibility, since we cannot guarantee privacy of any medical information once it reaches that electronic medium.

In signing this waiver, I understand and attest to the fact that I am permitting the electronic conveyance of medical information to me through:

telephone

Please complete this field.

Fax

Please complete this field.

E-mail

Please complete this field.

Other Person (Who?)

Please complete this field.

knowing that these are unsecured electronic or communication lines and that Advanced Women's Health Institute is completely without fault or legal responsibility if a third party obtains this information without my permission.

Best way to contact you about results of medical tests:

Please select an option.

May we leave detailed information:

Please select an option.

I acknowledge that I have received and understand my rights under HIPAA regulations.

I authorize the release of information to my insurance as needed to process my claim

I have read the Patient Care Agreement included in this packet and understand and accept.

Printed patients name

Please complete this field.

Date:

Please complete this field.

Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Subscribe to updates from Advanced Women's Health Institute