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CAROLINAS ENDOCRINOLOGY
1594 Freedom Blvd., Suite 102B
Florence, SC 29505
Phone(843) 673-7560
Fax(843) 673-7563
As a patient, you have the right to confidential communication regarding your treatment and/or care.
I WISH TO BE CONTACTED IN THE FOLLOWING MANNER
(check all that apply)
Home
[ ] yes; phone # _________________ [ ] no
[ ] O.K. to leave message with detailed information
[ ] Leave message with call-back number only
[ ]Written Communication
[ ] O.K. to mail to my home address
[ ]O.K. to mail to my work/office
[ ] O.K. to fax to this number
_________________________
Work
[ ] yes; phone #__________________ [ ] no
[ ] O.K. to leave message with detailed information
[ ] Leave message with call-back number only
[ ]Other _______________________
______________________________
______________________________
__________________________________________
Patient Signature
__________________________________________
Print Name
COMMUNICATION OF PHI FORM
______________________________
Date
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