2208 University Blvd Suite 102
Birmingham, AL 35233

Login/Register
Pay Bill
Alabama Lifestyle Medicine - Dr. Noah Gudel, D.O.

Events

Consent for Non-Secure Communication of PHI

CONSENT FOR NON-SECURE COMMUNICATION OF PROTECTED HEALTH INFORMATION (PHI)

Please complete this contract and submit.

I understand that Alabama Lifestyle Medicine (ALLM) has a secure (encrypted) email. Despite that, I request that the ALLM use non-secure (unencrypted) email, text, and/or video messaging to communicate with me on the following: Communications regarding my appointments: To send me copies of any records I have requested. For any communication about my health, treatments, and health care in general. I request that the ALLM use the following option(s) for non-secure communication with me by use of the following: Personal email, Text (SMS) messaging, Video messaging (such as Zoom or Skype), Client verbally consents

Name(Required)

I understand that non-secure email may be intercepted by persons other than the sender and recipient. I accept all liability for any/all consequences of using this non-secure communication option. I release ALLM from any/all liability from using non-secure communication at my direction. I understand that I am not required to sign this agreement in order to receive care from ALLM. I understand that I may terminate this consent at any time. This consent will remain in effect until I notify ALLM in writing or by email that I revoke my permission for this document

MM slash DD slash YYYY
Time(Required)
:

By:

Relationship to Patient (if other than patient)

Get Started on Your Wellness Journey

To speak to Dr. Gudel and embark on your wellness journey, contact Alabama Lifestyle Medicine by using the contact form or by emailing us.

Email

info@allifestylemed.com

Address

2208 University Blvd Suite 102
Birmingham, AL 35233

Send Us an Email

"*" indicates required fields

Alabama Lifestyle Medicine - Dr. Noah Gudel, D.O.

A Better Future.
Get More From Lifestyle Medicine.

Quick Links

Service Hours

  • Monday : 10:30AM - 5:00PM
  • Tuesday : 8:00AM - 5:00PM
  • Wednesday : 8:00AM - 5:00PM
  • Thursday : 8:00AM - 5:00PM
  • Friday : 8:00AM - 5:00PM
  • Saturday - Sunday : By Appointment

Follow us on Social Media

Facebook-f Instagram Linkedin-in

@2023 Copyright All Rights Reserved