30230 Rancho Viejo Road, Suite 200 San Juan Capistrano, CA 92675 Phone 949-443-4303 Fax: (949) 443-4033
16305 Sand Canyon Ave Suite 255 Irvine, CA 92618
New Patient forms Page 2
Patient Communication Consent Form
Patient Name: ____________________________________ Date of Birth: ____________________________
Email and Text Messaging Program Consent Form, we are happy to provide our patients with the option to
participate in our online patient communication system. Some of the features include the ability to:
1. Send or receive email communication from our office
2. Receive text message appointment reminders
4. Submit patient satisfaction surveys
6. Reminder to schedule follow up visits, wellness visits, and other important ordered and recommended tests.
7. We might also occasionally send information about special clinics we are running that you might be interested in.
You may choose to discontinue your participation in our online communication system at any time simply by
replying “STOP” to a text message from us. Standard text messaging rates may apply.
Cell Phone: __________________________________ (if you wish to receive text messages)
Email: ______________________________________ (if you wish to receive emails)
We use this information strictly for the purposes of communicating with you more efficiently. Our goal is to provide
you with excellent treatment as well as overall service and satisfaction. We may disclose patient health information
(PHI) to third parties that perform services for this practice in the administration of your benefits in accordance with
HIPAA. These parties are required by law to sign a contract agreeing to protect the confidentiality of your PHI. Your
PHI may be disclosed to an affiliate that performs services for this practice in the administration of your benefits.
Our affiliates do not sell, share or rent our users’ personally identifiable information unless required by law, do not
send any e-mail or other communications without your permission, and do not send spam. Please sign below to
indicate that you agree to allow us to use this information in providing your services
Authorization to Disclose Information to Family Members/Friends
I, the undersigned, authorize Paloma Medical Group to disclose all of my medical information to the following
______________________________________ The expiration date for this authorization is ____/____/____ unless I
revoke or terminate this authorization. I understand that I have the right to revoke or terminate this authorization by
submitting a written revocation to Paloma Medical Group. I understand that the information disclosed under this
authorization may be disclosed again by the person or organization to which it is released. The privacy of this
information may not be protected under federal privacy regulations.
Acknowledgment of Receipt of Paloma Medical Group’s “NOTICE OF PRIVACY PRACTICES”
I, (patient’s name): __________________________________acknowledge that I have received a copy of Paloma
Medical Group’s notice of privacy practices. This notice describes how Paloma Medical Group may use and disclose
my protected health information, certain restrictions on the use and disclosure of my healthcare information and the
rights I have regarding my protected health information.
Patient/Guardian Signature _________________________________ Date ____________________________
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