HIPPA AUTHORIZATION

I, *, authorize Southeastern Dermatology Consultants, PC, and its employees the following:
Please Select

I do/ do not want employees to call and remind me of my appointment.

They may/ may not leave a message at my home telephone number.

They may/ may not contact me on my cell phone.
They may/ may not call me at work and/or leave a message.
They may/ may not contact me via email.

I do/ do not wish to be placed on the monthly e-newsletter list.

They may/ may not release information and/or test results to my physician.

They may/ may not leave test/pathology results on my answering machine.

They may/ may not give test/pathology results and/or discuss my care with:


Name
Relationship

Name
Relationship

Email address* 		 

This authorization will remain in effect until I provide written instructions otherwise.



Patient's Signature* (if minor, guardian's signature)
Date

 


(865) 474-8800
Home | About Us | Patient Resource Center | FAQ | Care Credit | Contact Us | Site Map
© 2010 Southeastern Dermatology Consultants. All rights reserved.
Powered by www.ekwa.com
Southeastern Dermatology Consultants
1924 Pinnacle Pointe Way, Suite 300
Knoxville, TN 37922
Phone: (865) 474-8800 | Fax: (865) 474-8806