HIPAA Form

 

 

 

 

HIPAA RELEASE FOR TELEPHONE CORRESPONDENCE

 

 

 

Millennium Health & Wellness has my permission to contact me using any of the following methods:

 

 

______ May leave a message at home on answering machine

 

 

______ May leave a message at home with spouse/family member

 

 

______ May call and leave message on my cell phone _______________

 

                                                                                      cell number                     

           

______ May leave a message at work

 

 

 

I understand that Millennium Health & Wellness will be contacting me strictly for general information, scheduling, or billing questions.

 

 

 

 

_____________________________________                     ______________

 

Patient’s Signature                                                                       Date

 

 

 

______________________________________

Patient’s Name (Please Print)