Patient Contact Authorization Patient Contact Authorization PLEASE NOTE THAT (COMPANY NAME) DOES NOT DISCLOSE OR SELL ANY PATIENT PROTECTED HEALTH INFORMATION TO ANY THIRD-PARTY BUSINESS OR ONLINE DATABASE. I, the undersigned, authorize ANEW, LLC., DBA ANEW, BODY, BEAUTY AND WELLNESS SPA (“Practice”) to contact me according the policies of Practice regarding facets of my care, including requests for information, verification of payment or benefits, and reminders for appointments. I understand and accept that Practice may leave messages on home or cell phone answering systems or send reminder cards by U.S. mail, email or text message, according to the policies of Practice. Name(Required) First Last If Practice needs to communicate with me regarding my treatment, my preferred method of communication is as follows (check one): Phone Text Message Email Other Phone Number(Required)Email(Required) Please Specify(Required) I understand that if I have chosen a phone call as my preferred method of communication, Practice may be required to leave a voicemail for me regarding my treatment. In such an event, Practice should (check one):(Required) Leave a message with detailed information regarding my treatment. Leave a message requesting that I call Practice at a specified phone number. I understand that, from time to time, Practice may utilize email or text messages to communicate with me both about my treatment and for marketing purposes. I understand that these emails or text messages may include appointment reminders, general health reminders, feedback requests, newsletters and other information relating to Practice. Accordingly, I (check one):(Required) Authorize Practice to email or text me for both treatment and marketing purposes. Authorize Practice to email or text me appointment and health reminders only. Do not authorize Practice to email or text me. I understand that this authorization will remain in effect until I either submit a subsequent Patient Contact Authorization changing my above stated preferences, or I revoke or withdraw this authorization in writing. To do so, I must send written notice to Practice at 2004 US HIGHWAY 98, STE C, DAPHNE, AL 36526. I acknowledge and agree that Practice and its employees, officers and physicians are released from any legal responsibility of liability for or resulting from the authorized disclosure of my health or billing information.Patient Signature(Required)Date(Required) MM slash DD slash YYYY Daljeet Arora2022-10-28T14:05:51+00:00
