Contact Record

1. May we leave confidential messages regarding appointments, return calls, etc. with anyone who answers the telephone at your home?

Yes
No

2. May we leave confidential messages regarding appointments, return calls, etc. on your home answering machine or voicemail?

Yes
No

3. Is there a number other than your home number where we can leave a confidential message with anyone answering the telephone regarding appointments, lab results or other healthcare information? (Example: Cell Phone, Relative, Caregiver)

Yes
No

If yes, please list numbers and relationship(s)

4. If we are unable to reach you by any of the above options, may we leave confidential messages regarding appointments, return calls etc at your place of employment
Yes
No
N/A

If we are unable to reach you by any other means, we will send information through the U.S. Postal Service to your home address.

We keep a record of each visit. This record may include your test results, diagnoses, medications, and your response to medications or other therapies. This allows your doctor and other clinical staff to provide appropriate care to meet your needs. The information in your record is called protected health information. We may disclose your protected health information to other health care providers or entities involved in your care in order to coordinate treatment and provide continuity of care.

I understand that my protected health information may be used to coordinate my treatment as described above. I have been given a copy of the University Health System, Inc. (UHS) Notice of Information Practices. I understand that this Notice describes how my health information may be used or disclosed by this practice, UHS, UHS Ventures Inc. (UHSV) and physicians and other providers practicing at UHS or UHSV facilities and that I should read it carefully. I am aware that the Notice may be changed at any time.