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Request for Confidential
Communication

 

hereby request Demo Healthcare, PA to keep communications regarding my protected health information confidential. To accomplish this request please adhere to the following requests: 

Our preferred method of communication is through our secure patient portal.
Providing your
email address allows us to invite you to join our portal.


Preferred Contact Format:

Button EmailEmail Button PhonePhone Button FaxFax


I give authorization to the doctors and staff of Demo Healthcare to discuss any of my medical and/or financial information with the following people:

Button Contact 1Contact 1 Button Contact 2Contact 2 Button Contact 3Contact 3


I understand that the Notice of Privacy Practices is available on the practice website and at my physician’s office. I acknowledge receipt of Demo Healthcare’s privacy policy. A paper copy is available upon request.
This request may be changed or revoked by filing a new request or revoking this one in writing.

Patient Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.