Confidential Communications
In order to protect your privacy, we ask that you complete this form so we know the ways in which we may communicate
with you regarding your health information. Please mark as many of the communication options below you feel
comfortable with so we have multiple ways to reach you regarding important matters concerning your health care.
Patient Name: ____________________________________
Date of Birth: _____________________
Text message Phone Call
I prefer to receive my appointment reminders in the following method:
I authorize White House Clinics, its providers and employees, to do the following:
Leave a message at my home/cell number in regards to appointment reminders/scheduling.
Yes No
It is important that you always keep your home/cell number updated with White House Clinics
Send me a letter in the mail in regards to appointment reminders/scheduling.
Leave my test results in a message at my home/cell number.
Send my appointment reminders in a text message.
Send my appointment reminders in an email.
Yes No
Yes No
Yes No
Yes No
Yes No
Send my test results in the mail.
I authorize White House Clinics to discuss my healthcare as indicated with the following individuals:
Name:
Relationship:
Phone:
Give the following information to this individual (circle all that apply):
Appointment Reminders
Test Results
Billing Information
Name:
Relationship:
Phone:
Give the following information to this individual (circle all that apply):
Appointment Reminders Test Results
Billing Information
White House Clinics conducts periodic patient satisfaction surveys. Survey respondents are chosen at
random. If you are chosen to receive the survey, you will receive a text message to share your opinion
regarding your recent experience at our clinic. Please note text message rates may apply.
I would like to participate in White House Clinics Patient Satisfaction Survey. I consent to receiving text
messages regarding my recent experience.
Yes No
I understand that I have the right to change or cancel this request at any time by notifying the Privacy Officer, in
writing, at Health Help Inc., Attention: Privacy Officer, 401 Highland Park Dr., Richmond, KY 40475. I also
understand that the changes or cancellation will not affect action taken based on this request prior to the change or
cancellation.
____________________________________________
______________________________________
Signature of Patient/Representative and Date
Printed Name of Patient/Representative
_____________________________________________________________________
Witness Signature and Date
Expiration: Yearly