Agreement to Receive Messages Containing Protected Health Information (PHI)
I DO NOT authorize Doctor or his/her designee to leave a message containing PHI necessary for my case.
I hereby authorize:
All Mount Sinai Doctors providers or their designees
Doctor or his/her designee
to leave a message containing PHI necessary for my care as follows:
On my answering machine at home AND with anyone who answers my phone
On my answering machine at home AND with anyone who answers my phone
ONLY at the following telephone number:
Patient Signature
{Personal Representative to sign only if patient is a minor or unable to sign on his/her own behalf}
Signature Personal Representative