AUTHORIZATION TO SHARE PATIENT INFORMATION - PEDS

Authorization to Share Patient Information

Name:*

First Name

Middle Name (optional)

Last Name

Date of Birth:*

Phone Messages

Is there a phone number where Hoag Medical Group can call and leave detailed messages regarding your child’s care, appointment/health screening reminders and other health care messages?*

No Yes

Please provide phone number:*

Text Messages

Do you wish to receive appointment/health screening reminders and other health care messages via text regarding your child?*

No Yes

Please provide preferred phone number to receive text messages:*

E-Mail

Do you wish to receive appointment/health screening reminders and other health care messages via e-mail regarding your child?*

No Yes

Please provide preferred e-mail address:*

Additional Contact

Is there someone else who Hoag Medical Group can leave detailed messages with and share your child’s patient information?*

No Yes

Name:*

First Name

Last Name

Relationship to Patient:*

Phone Number:*

I hereby consent to receiving messages regarding my child, as indicated above, from Hoag Medical Group and its affiliates. These parties may use the provided information to contact me by e-mail, live agent, voice mail, text message or pre-recorded message, including by using an auto-dialer or other computer assisted technology, or by any other electronic communication for purposes that include appointment and follow-up health care reminders, pre-registration, surveys, prescription information, health-related products or services that may be of interest, my account(s), assignment of benefits, and financial responsibility. I understand that depending on my phone plan, I could be charged for these calls or text messages. I also understand that providing this contact information and consent are not conditions to my child receiving health care services. With respect to text messages, I understand that I can opt-out at any time by replying “STOP” to the text message from my mobile device.

This Authorization to Share Patient Information remains in effect until a request to withdraw this form is submitted in writing by the patient or the patient’s legal representative.

Patient Signature*

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Date*

Site:*

If signed by other than patient, indicate legal relationship to patient: