HIPAA Compliance Communication Log Form
Use this form to record healthcare-related communications, document the participants, summarize the message, and note any follow-up or confidentiality details.
Communication Event Details
Communication Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Communication Time
*
Hour Minutes
AM
PM
AM/PM Option
Communication Type / Channel
*
Phone Call
Voicemail
Email
Text Message
Fax
In-Person Meeting
Secure Portal Message
Other
Direction of Communication
*
Incoming
Outgoing
Internal
Subject or Reason for Communication
*
Brief Summary of Communication Content
*
People and Care Context
Patient or Client Name
*
First Name
Last Name
Patient or Client Identifier (last 4 digits only)
Sender/Initiator Name and Role/Title
*
Recipient Name and Role/Title
*
Department or Practice Area
*
Please Select
Primary Care
Specialty Care
Behavioral Health
Billing
Care Coordination
Front Desk
Other
Preferred Callback/Contact Method for Follow-up
Phone
Email
Secure Message
Mail
No Follow-up Needed
Other
Authorization, Outcome, and Follow-up
Communication Status
*
Completed
Voicemail Left
Message Delivered
Pending
Outcome / Response Received
Follow-up Required?
*
Yes
No
Follow-up Action Needed
Follow-up Due Date and Time
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Confidentiality or Disclosure Noted
Special Instructions or Additional Notes
Submit Log
Should be Empty: