Phone: 212-570-6800 Fax: 212-861-7964 Fax: 212-734-7425
HIPAA DISCLOSURE AND CONSENT FOR TELEPHONE NOTIFICATION In our ongoing efforts to improve the quality of the patient care we deliver, we are notifying patients of their appointments telephonically a day or two prior to their scheduled appointment. We need your written permission to call you at home and/or leave a message with whomever answers your home telephone or leave a message on your answering machine, if you have one. I, _______________________________ (patient’s name), am aware that New York Urological Associates, P.C. pre-confirms appointments via an automated telephone system. My signature below authorizes you to include me in the appointment process. I understand that I can revoke this in writing at any time. __________________________________ ___/___/___ Signature of Patient Date Or Authorized Representative |