Nash Dermatology is committed to safeguarding your protected health information. To communicate verbally with another individual of your choosing or to receive messages regarding an appointment reminder, test results, follow-up appointments, or other important messages from your providers, we are asking for your written permission. I authorize/do not authorize Nash Dermatology to leave messages for me when I am unavailable as indicated below:Check to Confirm Approval Method Cell Phone Home Phone Work Phone Email Cell PhoneCheck if Allowed to Leave Messages Approved Home PhoneCheck if Allowed to Leave Messages Approved Work PhoneCheck if Allowed to Leave Messages Approved Email Check if Allowed to Leave Messages Approved I authorize Nash Dermatology to discuss my protected health information with the following individuals: This does not allow for printed copies or electronic access to my protected health information.ListNameRelationship to PatientPhone NumberEmergency Contact Yes/No Add RemoveAdd as many as neededBy signing below, I hereby grant the above elected methods of communication about my protected health information. Furthermore, I understand that I may at any time change or rescind my elections either by completing a new form, or by written correspondence with this office; otherwise, this election is valid for 12 months. Patient Name Date of Birth MM slash DD slash YYYY Signature Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY Δ
