ࡱ> OQN bjbj 7ttttt8P$$$,Zt$$$$$tt4 $Ftt$S{P jjk 0Ps{t{8$$$$$$P$$$$$$$$$ ::    FUNDRAISING: OPT OUT DESIGNATION FORM The following individual has elected to opt-out of University Physicians of Brooklyn fundraising activities Patient Name: ________________________________________________________________ Last Name First Name MI Address: _____________________________________ Opt-Out Method Utilized: _____________________________________ ____ Phone ______Email _____________________________________ _________________ Other 1. Stop receiving ALL fundraising materials? __ Yes __ No; please describe what type of materials patient does not want to receive: __________________________________________________________________________ __________________________________________________________________________ 2. Title of the fundraising material sent by Department? (Optional) ____________________________________________________________________________ 3. Any reason that patient elects to opt-out of receiving future fundraising communications? (Optional) ________________________________________________________________________________________________________________________________________________________ A. If form is being completed by the patient on date of visit/ admission, complete this section: _____________________________________ ___________________ Patient Signature Date B. 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