Confidential Voicemail Authorization

Contact Content — Communication Authorizations

Allergy & Asthma Associates of Allen
977 Raintree Circle, Ste 100, Allen, Texas 75013
Phone: (972) 747-7007 | Fax: (972) 747-7006 | www.allenallergy.com

Complete this communication authorization form. All fields submit together in one email.

Patient Information

Patient Name

Date of Birth

Confidential Voicemail Authorization

Occasionally it may become necessary to contact our patient(s) by telephone.

In the event you are not available by phone, we will leave detailed voice messages regarding you/your child’s treatment. By providing your telephone number(s), you hereby grant Allergy & Asthma Associates of Allen permission to leave detailed voicemail messages regarding you/your child’s treatment.

My Cell Phone (for voicemail)

I do NOT wish to receive voicemails regarding me/my child’s treatment.

Permission to Share Personal Healthcare Information

I give permission for Allergy & Asthma Associates to provide my personal healthcare information to:

Authorized Person 1 — Name

Authorized Person 1 — Relationship to Patient

Authorized Person 2 — Name

Authorized Person 2 — Relationship to Patient

E-Mail Messaging Authorization

Email Address

Emails sent by Allergy & Asthma Associates of Allen are NOT SPAM. Emails sent to you will be items regarding you/your child’s treatment or appointment.

I do NOT wish to receive emails from Allergy & Asthma Associates of Allen

Text Message Authorization

My Cell Phone (for text reminders)

I do NOT wish to receive text message reminders regarding future appointments

Mailing Address

Street Address

City, State, Zip

Acknowledgement / Signature

Patient’s Printed Name

Patient’s Signature (type full legal name)

Date

Legal Representative’s Printed Name (if applicable)

Legal Representative’s Signature (type full legal name)

If Representative, Specify Relationship to Patient

I acknowledge the voicemail, email, text, and PHI-sharing authorizations above and confirm the information is accurate.