Consent to Receive Text Message Appointment Reminders
 

By signing below, I authorize {facility name} and its affiliates to contact me by automated SMS text message for appointment reminders.

I understand that message/data rates may apply to messages sent by {facility name} or its affiliates under my cell phone plan. My text/mobile phone number is: (      ) Patient Initials ____

I know that I am under no obligation to authorize {facility name} or its affiliates to send me text messages. I may opt-out of receiving these communications at any time by calling the Service Desk @ {facility number}, or Reply STOP to unsubscribe. Please allow 2-3 business days for processing.

I understand that text messaging is not a secure format of communication. There is some risk that individually identifiable health information or other sensitive or confidential information contained in such text may be misdirected, disclosed to or intercepted by unauthorized third parties. Information included in text messages may include date/time of appointments, name of clinician, and clinician’s phone number, or other pertinent information.

By signing below, I indicate I am the primary user for the mobile phone number listed above, I accept the risk explained above and consent to receive text messages via automated technology from {facility name} and its affiliates to the phone number that I have provided.

Patient Name: __________________________________
Signature: _____________________________________
Date: _____________ Date of Birth: _______________

Fax: Patient Services Contact Center
Attn: My Health Online, {facility number}

Mail: Patient Services Contact Center
Attn: My Avenues
{facility address}