I understand protected health information is information that identifies me. The purpose of this authorization is to allow Norman Urology Associates, P.C. to share my protected health information.
I authorize Norman Urology Associates, P.C. as set for the below, to share my protected health information for medical and personal reasons, in addition to those already permitted by law.
*By supplying my home phone number, mobile phone number, email address, and any other personal contact information, I authorize my health care provider to employ a third-party automated outreach & messaging system to use my personal information, the name of my care provider, the time and place of my scheduled appointment(s), and other limited information, for the purpose of notifying me of a pending appointment, missed appointment, overdue wellness visit, or any other reasonable healthcare related communication. I also authorize my healthcare provider to disclose to third parties, who may intercept these messages, limited protected health information regarding healthcare events, unpaid balances, missed appointments, and to leave a reminder message on my voice mail or answering system if I am unavailable at the number provided by me.*
Select all that apply
12 months from the date signedUntil revoked
I understand I may change this authorization at any time by writing to the address listed at the bottom of this form. I understand I cannot restrict information that may have already been shared based on this authorization.
This document must be signed by the individual or the individual’s legal guardian/representative.
Patient’s Name (Note: By entering your name in this box, constitutes a signed document (you will be asked to sign in person at your appointment
Norman Urology Associates, PC accepts denies conditionally the restrictions imposed on release of information as stated above.