With my consent, Oaks Medical Center may call my home and leave a message on voice mail in reference to any terms that assist the practice carrying out treatment, payment or health care operations, such as appointments reminders, insurance items, and any call pertaining to my clinical care including diagnostic results among others.

With my consent Oaks Medical Center may mail to my home or other desigated location any items that may assist my carrying out treatment, payment or health care operations, such as appointment reminders and patient statements as long as they are marked personal and confidential.

With my consent, Oaks Medical Center may e-mail to my home or other designated location any items that assist in the treatment, payment or health care operations, such as appointment reminder cards and patient statements.
E-mail:

By signing this form I am consenting to Oaks Medical Center's use and disclosure of my personal health information to carry out treatment, payment or health care operations.

I may revoke my consent m writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, Oaks Medical Center may decline to provide treatment for me.

Signature of Patient or Legal Guardian	Email
Patient's Name	Date