Communicating with You

In order to effectively communicate with you about your medical information we request that you complete this form identifying the best ways to provide you with your confidential information. We may need to communicate test results, prescription information or respond to a message you left for your physician’s office. We may communicate with you through mail, secure email, and telephone, including leaving messages on your answering machine/voice mail.

Please check all boxes that you give South Island Medical permission to use for your communications:

□ You may leave a detailed message/voice mail Phone Number:______________________ or Phone Number:______________________
□ You may contact me through email (and/or Patient Portal)

If you give permission for us to communicate with anyone else, please complete this list below:

Name/Phone Number	Relationship	Options
1.	□ Billing Information □ Appointment Information □ Medical/Health Information
2.	□ Billing Information □ Appointment Information □ Medical/Health Information
3.	□ Billing Information □ Appointment Information □ Medical/Health Information

This request supersedes any prior request for communication of information I may have made.

______________________________________	______________________________

Signature of Patient/Responsible Party	Date

______________________________________	______________________________

Name of Patient (Print)	Name and Relationship if not Patient

___________________

DOB