Healthcare IVR Form

HEALTHCARE IVR FORM

Purpose: This form documents patient contact information, communication preferences, and written authorization to receive automated interactive voice response (IVR) calls, prerecorded messages and text messages for appointment reminders, clinical communications, billing and administrative notifications. By completing and signing this form the patient or authorized representative grants the limited consents set forth below and acknowledges the terms and privacy statements that follow.

Patient Information

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History (Brief)

IVR / Automated Communications Authorization

Healthcare Provider Name:

I hereby authorize the Healthcare Provider named above, and its agents or designated service providers, to contact me at the telephone number(s) and email address(es) provided on this form using automated dialing equipment, prerecorded/artificial voice messages, and SMS/text messages, including messages that may contain limited protected health information necessary for the purpose described in this authorization.

Primary IVR Contact Number:    Secondary IVR Contact Number:

I authorize the following message types (check all that apply):

Appointment reminders and scheduling communications
Billing, insurance or payment notifications
Clinical communications regarding care or treatment (test results, medication instructions)
Non-marketing administrative messages (patient surveys, service announcements)

I understand and agree that:

1) Messages may be prerecorded or delivered by an automated system; 2) Message frequency will vary based on my care and administrative needs; 3) Carriers may impose fees for text messages or calls and I am responsible for such charges; 4) Messages may contain limited protected health information necessary for the stated purposes; and 5) This authorization applies to the phone numbers and email addresses listed on this form and any updated numbers I provide in writing.

Revocation: I may revoke this authorization at any time by delivering a written revocation to the Healthcare Provider named above. Revocation will be effective upon receipt, but will not apply to communications already sent or where the provider has relied upon this authorization prior to processing the revocation.

This authorization is not a condition of treatment. Refusal to sign will not affect my ability to obtain treatment or insurance benefits. Unless an earlier expiration date is specified below, this authorization will remain in effect until revoked.

Privacy Notice Acknowledgment

I acknowledge that I have been provided with the Notice of Privacy Practices explaining how my protected health information may be used and disclosed in connection with automated communications. I understand that the communications authorized by this form may include limited health information and that the provider will take reasonable steps to protect my information in accordance with applicable law.

I acknowledge receipt of the privacy notice and consent to the uses and disclosures described above.

Certifications

By signing below I certify under penalty of perjury that the information provided on this form is true and correct to the best of my knowledge and that I am the subscriber or otherwise authorized to provide consent for the use of the telephone numbers and email addresses listed above. I understand the terms of this authorization and agree to receive automated communications as indicated.

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