Patient Confidential Communications Authorization

Welcome!
Your provider has enlisted Savant Medical Billing service to support the financial management portion of your care.
If you are a new patient or a current patient and need to complete the
Patient Authorized Communication Form
You may complete this form electronically by scrolling down and filling in all the boxes with your information then select the "Submit" button, or if you prefer to fax SMB the form you may download a PDF file by selecting the P.A.C.C. Agreement form button here.

P.A.C.C. Agreement Form

Request for Electronic Submission of:

Patient Authorized Confidential Communications (P.A.C.C.)

When using the electronic format here to authorize your confidential communications preferences,
please read each section below and fill in your information.
Each section applies to the complete P.A.C.C. agreement.
If incorrect or incomplete information is provided, the agreement cannot be recorded. Thank you!

* Indicates required field

I, *

First

Last

hereby attest, to be the legally named party for the information I input, and agree by entering my legal registered name, on file with my state, and federal registrars; I have read and acknowledged the P.A.C.C. agreement, on this web page. I agree, to add the following authorized contact information into the area provided here: my phone, e-mail and mailing address. This authorization, I am providing shall be valid; until I provide written request to Savant Medical Billing, voiding my authorized communication preferences.

I, *

First

Last

am providing below, my authorized email. I agree, my current healthcare provider, and their business associate Savant Medical Billing (SMB), may email me with notifications that may include my Private Health Information. My email, shall only be accessed, for the management of: my financial account, heath insurance benefit coordination, and/or scheduling processes in the normal course of business. I understand, I am authorizing the provided email address, and it will be a valid communication route; until, I provide SMB with a completed, Request to Void/Withdraw the P.A.C.C. Agreement letter. I agree, I have been notified that a downloadable version is provided, as a courtesy by SMB, on this web page.

Patient Authorized Email *

I, *

First

Last

am providing my authorization below, to use my USPS mailing address. I agree, my current healthcare provider, and their business associate; Savant Medical Billing (SMB), may send USPS mail, to me with notifications that may include my Private Health Information. My authorized USPS mailing address shall only be accessed, for the management of my: financial account, heath insurance benefit coordination, and/or scheduling processes in the normal course of business. I understand, I am authorizing my USPS mailing address, and it will be a valid communication route; until, I provide SMB with a completed, Request to Void/Withdraw the P.A.C.C. Agreement letter. I agree, I have been notified that a downloadable version is provided, as a courtesy by SMB, on this web page.

Authorized USPS Mailing Address *

Line 1

Line 2

City

State

Zip Code

Country

Please select a Primary Preference of Communication.

Preferred Method of Communication *

E-mail Phone Call Text via Phone USPS delivered Mail

Thank you for your participation in completing the steps for electronic communications to take place. The steps above are defined by state and federal HIPAA regulations. Compliance is required by your healthcare provider and their business associates, in order to protect your Private Health Information when communicating Personal Health Information to you.

Submit

By contacting Savant Medical Billing through this electronic format I acknowledge and agree with SMB's E - Privacy Policy