Healthcare Appointment Reminders

HEALTHCARE APPOINTMENT REMINDERS

Purpose: This form documents the patient's authorization to receive appointment reminders and related non-sensitive communications from the practice. Completed information and selections below authorize the practice to contact the patient and any authorized third parties by the methods and at the contact points provided for the purpose of scheduling, confirming, rescheduling, or cancelling appointments.

Patient Information

Insurance (optional)

Medical History (brief)

Consent to Receive Appointment Reminders

I authorize the practice to use the contact points and methods selected below to send appointment reminders and related scheduling communications. I understand that such communications may be transmitted by voice call, automated telephone dialing system, prerecorded message, text message, or electronic mail as selected. I acknowledge that message content will be limited to appointment scheduling and related operational notices and will not include clinical diagnoses or detailed medical information unless I have separately authorized such disclosures.

I understand that I may incur message or data charges from my carrier for electronic messages and that the practice is not responsible for such charges. I understand that I may revoke this authorization at any time by providing a written request to the practice; revocation will be effective after the practice receives and has a reasonable opportunity to act on the revocation. This authorization will remain in effect until the earlier of the expiration date provided below or receipt of revocation.

Contact Preferences & Authorization

Allow the practice to contact me at the following methods (check all that apply):

Authorized Third Parties

If you authorize the practice to leave appointment information with another person, list the authorized individuals below. The practice may release reminder information (date, time, location) to the persons named.

Timing and Frequency of Reminders

Select the types of reminders you consent to receive:

Privacy Acknowledgment

I acknowledge that the practice's communications described above may include appointment details but will not include detailed clinical information unless I separately authorize such disclosures. I have been provided the opportunity to review the practice's privacy practices and understand how the practice may use and disclose my information for appointment communications.

Authorization Duration and Revocation

This authorization will remain effective until the date specified below, or until I revoke it in writing. Revocation requests must include the patient name and signature and will be effective once received and processed by the practice.

Additional Instructions or Limitations

Certification and Signature

By signing below I certify that I am the patient named above or the patient's legally authorized representative. I have read and understand the terms of this authorization. I authorize the practice to send appointment reminders consistent with my selections above.

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