In an effort to communicate with you in the manner in which you prefer, we are asking for permission to contact you via email, telephone calls to your landline or cellular telephone (including prerecorded/artificial voice messages and/or calls from an automatic dialing device), voicemails, and/or text messages. Communications may be made to confirm an appointment, to obtain feedback, or to provide health reminders and health care information and services. We do not charge for these communications, but standard text messaging rates, data pricing, and/or cellular telephone minutes may apply as provided in your telephone service plan (contact your telephone carrier for pricing plans and details).


The privacy and security of protected health information is protected by state and federal laws, including the Health Insurance Portability and Accountability Act (HIPAA). Although it is our preference not transmit protected or confidential information via unsecure means, we may, at the direction of a patient or his/her authorized representative, use unsecure/unencrypted methods to transmit protected information.

Prior to providing an email address or telephone number below, you should consider that communications via these means are unsecure and consider whether to provide a personal or a work email address or telephone number. If you choose to provide a work email address or telephone number, potentially-sensitive information may reside under the control of your employer. Transmissions via unsecure/unencrypted means may present risks, such as:

  • Messages can be intercepted, altered, forwarded, circulated, misdirected, stored, and/or used without authorization or detection.

  • Copies may exist in backups, or otherwise, even after the sender and the recipient have deleted the messages.

  • Messages can introduce viruses and other malware into your computer system or device.

  • Employers and online service providers may have a right to inspect messages transmitted through their systems.


I hereby authorize and direct Medicorp, PA d/b/a My Family Doctor (“Medicorp”) to use and disclose medical records of the individual identified above for the purposes of providing appointment reminders, health information, and health care information and services and for obtaining feedback via the communication methods identified below. By providing an email address or telephone number below, I consent to receiving communications via these means. Despite the risks of doing so, I authorize and direct Medicorp to transmit information for these purposes via the following unsecure/unencrypted means:

Please complete this section by selecting some or all of the options above and by providing the relevant contact information.

By signing below, I acknowledge that my signing of this Authorization is a voluntary act, that the information to be used and disclosed may be protected by law, and that the use/disclosure is to be made to conform to my directions. I understand that I do not have to sign this form and that my treatment, payment, or eligibility for services will not be denied if I do not sign this form.

I understand that I may revoke this Authorization at any time, except to the extent that action has already been taken in reliance upon it. If I do not revoke it, this Authorization will expire one (1) year after the date on which this Authorization is signed. To revoke this Authorization, I understand I must contact Medicorp in writing at the following address: Medicorp, PA, Attn: Privacy Officer, 1315 St. Joseph Pkwy., Ste. 1310, Houston, TX 77002. Information used and/or disclosed pursuant to this Authorization will not be protected by the Health Insurance Portability and Accountability Act (HIPAA) and may also be re-disclosed by the recipient, unless otherwise prohibited by law.

I acknowledge and agree that I have carefully read and understand the foregoing, have had an opportunity to ask questions, and have had all of my questions answered. I also represent and warrant that I have the full legal authority to agree to and to sign this Authorization myself or on behalf of the party identified above. I understand that by signing this form, I am authorizing the use and/or disclosure of confidential protected health information and the use of the communication methods identified above. I understand, consent to, accept, and assume all risks and liabilities associated with transmitting information via the methods identified above. I acknowledge and agree that Medicorp shall not be liable for any Breach with respect to the information addressed herein.

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If you are not the patient, but are signing on behalf of the patient, please complete the following and provide supporting documentation


confirm that I am the legal representative of the patient identified above based upon the following relationship:

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