Declaration of SUPPORT for OpenEMR. 

Today, {DOS} I want to DONATE!


{City}, {State}

This Practice and my official health care provider {ReferringDOC}, uses OpenEMR. 
This is a GNU licensed freeware supported Software Development program.
To continue Development of OpenEMR there are certain parts that are in need of financial support to continue compliance with Official State of {State} Requirements.

Users in the United States have reaped the bounty of the EHR Bonuses. Probably will do so again in the next Stages for certification. The majority of users, outside of the United States, have benefited from this Software product as well. Also through enhancements as Electronic Prescribing, Clinical Reminders and Secure Messaging. The experience of our colleagues abroad will continue to improve with further Certification.

See more at: http://www.open-emr.org/#sthash.yEQDXH6d.dpuf

I acknowledge receipt of this notice, and my understanding and my agreement to its terms, and are informed that my Financial Support can be tax deductible under the State of {State} laws, but can not be graranteed by my health care provider. 

Patient Name: 	{PatientName}  (FirstName Lastname); {PatientSex} (in characters)
		{PatientID}    ( External ID); Born: {PatientDOB}   (yyy-mm-dd) 
Home Address: 	{Address}  (Example: street address only i.e. 1224 Oakdale Rd.)
Zip: 		{Zip}; City: {City}; State: {State}
Home Phone: 	{PatientPhone}  (output in this form: (000)000-0000)




{PatientName}		        		
Patient Signature: 
			


					_________________________ 

Date: {DOS}          (Date of service)





I would like to have my Doctor keep track in an EHR of my medical problems in the mosr recent updat available of reliable OpenEMR. 
With my DONOATION I want to support the OpenEMR Software.



Patient Communications excerpt (HIPAA compliance): 
Health Insurance Privacy Act 1996 requires we inform you of the following government stipulations in order for us to contact you with educational and promotional items in the future via email, U.S. mail, telephone, and/or prerecorded messages. We WILL NOT ever share, sell, or “SPAM” your personal contact information, nor will do marketing any communication about a product or service that encourages recipients to purchase or a product or service. Communication can be defined as Voice Blasts, Email, and numerous marketing pieces. Communications to describe health-related products or services, or payment for them, provided by or included in a benefit plan of the covered entity making the communication. 




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