Request for Communication of Medical Information by Confidential or Alternate Means or Locations – Medical

NATIVE HEALTH is committed to maintaining the confidentiality of your health information and to allowing you to choose how we communicate with you.

If you do not want NATIVE HEALTH to communicate with you using the contact information you provided in your registration form, you may designate a preferred method or location for NATIVE HEALTH to communicate with you by completing this form.
Alternate Address for sending mail:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Alternate phone number(s):
Alternate phone number(s):
For alternate phone number(s):
- May leave a voicemail message
- May send a text message
Alternate e-mail address(es):
Alternate e-mail address(es):
By signing below, you are consenting to NATIVE HEALTH communicating with you using the address(es) and phone number(s) identified above and not using the information you provided during your registration. You also understand that NATIVE HEALTH cannot guarantee the security of messages sent through e-mail and that there is a risk that e-mail that is not encrypted may be intercepted. You understand that you may change your contact preferences by notifying NATIVE HEALTH in writing.

Patient/Legal Representative Signature
First Name*
Last Name*
Email*
Date*
MM slash DD slash YYYY
Authority to Act if Signed by Legal Representative*
- Yes
- No
AUTHORIZATION TO DISCLOSE HEALTH INFORMATION TO FAMILY AND FRIENDS

If you want NATIVE HEALTH to be able to discuss your health information with any family members or close friends, please identify those individuals by name and their relationship to you:
First Name
Last Name
Relationship to Patient
First Name
Last Name
Relationship to Patient
First Name
Last Name
Relationship to Patient
First Name
Last Name
Relationship to Patient
Patient/Legal Representative Signature
First Name*
Last Name*
Email*
Date*
MM slash DD slash YYYY
Authority to Act if Signed by Legal Representative*
- Yes
- No
CONSENT TO COMMUNICATE BY EMAIL OR TEXT MESSAGING

NATIVE HEALTH, its patients, and their representatives often find it convenient to communicate by e-mail or text messaging. Such communications may include, but are not limited to, appointment reminders, providing test results, information about available services, customer survey requests, marketing of goods and services, and other important notices related to NATIVE HEALTH.

Because email and text messaging are not secure methods of communication, there is some level of risk that the email or text message could be read by a third party and NATIVE HEALTH cannot assure the confidentiality of information that it sends to you, or that you send to NATIVE HEALTH over email or through text messaging.

By signing below, you are authorizing and agreeing: to NATIVE HEALTH sending you email or text messages at the following address(es)/number(s) or at such other addresses or numbers you have provided to NATIVE HEALTH or may provide in the future; and that such calls or messages may be sent using an automatic telephone dialing system or prerecorded or artificial voice:
First Name*
Last Name*
Initial here if you are willing to receive NATIVE HEALTH promotional or marketing messages at the phone number(s) and/or email address(es) above.
You are not required to agree to accept such calls or messages from NATIVE HEALTH as a condition of receiving services.

Note that you should never communicate by email or text message with NATIVE HEALTH about any matter that is time sensitive or if you are experiencing an emergency. Please call NATIVE HEALTH directly, OR IN AN EMERGENCY, CALL 9-1-1.

I have read and understand this Consent to Communicate by Email or Text Messaging and consent to NATIVE HEALTH communicating with me as described above.

Patient/Legal Representative Signature
First Name*
Last Name*
Date*
MM slash DD slash YYYY
Authority to Act if Signed by Legal Representative*
- Yes
- No

Request for Communication of Medical Information by Confidential or Alternate Means or Locations – Medical

AUTHORIZATION TO DISCLOSE HEALTH INFORMATION TO FAMILY AND FRIENDS

CONSENT TO COMMUNICATE BY EMAIL OR TEXT MESSAGING