Arrhythmia Patient Hipaa Acknowledgment And Consent Form Page 2

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Consent to Email or Text Usage for Appointment Reminders and Other Healthcare Communications:
Patients in our practice may be contacted via email and/or text messaging to remind you of an appointment, to obtain
feedback on your experience with our healthcare team, and to provide general health reminders/information.
If at any time I provide an email or text address at which I may be contacted, I consent to receiving appointment reminders and
other healthcare communications/information at that email or text address from the Practice.
______ (Patient initials) I consent to receive text messages from the practice at my cell phone and any number forwarded or
transferred to that number or emails to receive communication as stated above. I understand that this request to receive emails
and text messages will apply to all future appointment reminders/feedback/health information unless I request a change in
writing (see revocation section below).
The cell phone number that I authorize to receive text messages for appointment reminders, feedback, and general health
reminders/information is______________________________.
000 - 0000.
The email that I authorize to receive email messages for appointment reminders and general health
reminders/feedback/information is______________________________.
The practice does not charge for this service, but standard text messaging rates may apply as provided in your
wireless plan (contact your carrier for pricing plans and details).
Revocation
I hereby revoke my request for future communications via email and/or text.
__I hereby revoke my request to receive any future appointment reminders, feedback, and general health via text
messages.
__ I hereby revoke my request to receive any future appointment reminders, feedback, and general health via email.
NOTE: This revocation only applies to communications from this Practice.
Patient Name: ________________________________________________________
Patient/Patient Representative Signature: _______________________________________________
Date: _____________________________
Time: ____________________
Consent for Photographing or Other Recording for Security and/or Health Care Operations
____ (Patient Initials) I consent to photographs, videotapes, digital or audio recordings, and/or images of me being recorded for
security purposes and/or the practice’s health care operations purposes (e.g., quality improvement activities). I understand that
the facility retains the ownership rights to the images and/or recordings. I will be allowed to request access to or copies of the
images and/or recordings when technologically feasible unless otherwise prohibited by law. I understand that these images
and/or recordings will be securely stored and protected. Images and/or recordings in which I am identified will not be released
and/or used without a specific written authorization from me or my legal representative unless it is for treatment, payment or
health care operations purposes or otherwise permitted or required by law.
____ (Patient Initials) I do not consent to photographs, videotapes, digital or audio recordings, and/or images of me being
recorded for security purposes and/or the practice’s health care operations purposes (e.g., quality improvement activities).
Prescription Order Pick-up. There may be times when you need a friend or family member to pick-up a prescription order
(script) from your physician’s office. In order for us to release a prescription to your family member or friend, we will need to
have a record of their name. Prior to release of the script, your designee will need to present valid picture identification and sign
for the prescription.
____ (Patient initials) I wish to designate the following family member / friend to pick up an order on my behalf:
Name: _________________________________________________ Date: ___________________
Name: _________________________________________________ Date: ___________________
____ (Patient initials) I do not want to designate anyone to pick-up my prescription order.
Patient Signature ________________________________ Date: __________________________
Patient Name (Printed): _________________________ DOB: ________________________
Updated: June 12, 2015, replacing November 21, 2013 version

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