Last Updated: January 22, 2024
Authorization to Use and Disclose Protected Health Information
The privacy of your protected health information is important to us. Your “protected health information” (“PHI”) is defined under the Health Insurance Portability and Accountability Act, as amended, (“HIPAA”). To protect your PHI, we will follow federal and state privacy laws, including HIPAA. We refer to all of these laws as the “Privacy Rules.” We will use your PHI in accordance with our Notice of Privacy Practices.
I authorize HLTHX MSO LLC (“Company”) and its affiliates to contact me by automated Short Messaging Service (“SMS“) text message. I understand that message/data rates may apply to messages sent by Company or its affiliates under my cell phone plan. I understand it is my responsibility to update my mobile phone number that is listed with [Company] and its affiliates.
I know that I am under no obligation to authorize Company or its affiliates to send me text messages. I may opt-out of receiving these communications at any time by calling the Service Desk @ 312-535-9848, or by responding STOP to 312-535-9848. 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 your first name, date/time of appointments, name of physician, and physician 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 [Company] and its affiliates to the phone number(s) that I have provided.