Circle of Contacts
Name of Patient: __________________________________
Address: _________________________________________
Phone: __________________________________________
Patient’s Date of Birth: ______________________________
I _______________ give my informed consent to be contacted by Patient Sortal, including the collection of relevant per-
sonal information for the purposes of providing services I have agreed to. Additionally, if the established connection (phone,
email, text message) is no longer available to Patient Sortal, I give permission to Patient Sortal to reach out to person(s) or
entities on this form to reestablish connection.
By signing below, you understand and acknowledge the following:
• Patient Sortal is authorized to engage in discussion with person(s) or entities on this form to reestablish a connection with
you.
• Patient Sortal will not use this form as authorization to discuss your health.
• This form permits verbal communication only. This form does not allow the individuals listed below to obtain copies of your
medical records.
• This form applies only to Patient Sortal. If you receive health care from other medical practices, you will need to complete a
new form for each practice.
• This form is entirely voluntary and optional. Refusing to sign this form will not impact your care provided at this practice.
This form can be revoked at any time by calling Patient Sortal 1-833-728-1368. The consent remains in effect until you revoke
it in writing or sign a new form.
Name / Entity Relationship Phone Number
_______________________________________________
____________________________________________________
Signature of Patient or Legal representative
Print name
_______________________________________________
____________________________________________________
Date Time
Relationship to patient
_______________________________________________
____________________________________________________
Interpreter (if applicable)
Reason patient unable to sign
Are you residing at a housing program?
Do you work with a case manger outside of Patient Sortal?
Do you have a friend or family member who will have your up to date contact information?