Healthcare SMS Contract

HEALTHCARE SMS COMMUNICATION AGREEMENT

Parties and Effective Date

Healthcare Provider:

Emergency Contact Phone:

Insurance Information

Medical History (summary)

Description of SMS Services and Consent

The Patient authorizes the Healthcare Provider to send automated and manual short message service (SMS) communications to the Patient's mobile telephone number for the purposes described below. Communications may include appointment reminders, treatment and care instructions, prescription refill reminders, billing statements, care coordination messages, and administrative notifications. Patient acknowledges that messages may be generated by automated systems.

Effective Date:

Message Types and Preferences

Please indicate which SMS communications you consent to receive (check all that apply):

Appointment reminders and confirmations

Prescription refill and medication reminders

Billing, insurance, and payment notifications

Care instructions and clinical follow-up

Patient satisfaction surveys and administrative communications

Marketing communications are subject to explicit prior consent. I authorize marketing messages: (check to consent)

Risks, Costs, and Opt-Out

Patient understands and accepts that SMS is not a fully secure transmission method. Although the Provider will take reasonable measures to protect the content of messages, confidentiality cannot be guaranteed. Carrier message and data rates may apply. The Provider is not liable for charges imposed by the Patient's wireless carrier.

Patient may revoke consent at any time by replying STOP to any SMS received, by contacting the Provider in writing, or by calling the Provider's administrative contact. Revocation will be effective within a reasonable time to process the request but will not affect the lawfulness of messages sent prior to revocation.

HIPAA Acknowledgment and Authorization

By signing below, Patient acknowledges receipt of the Provider's Notice of Privacy Practices and authorizes the Provider and its agents to use and disclose protected health information via SMS as necessary to provide the communications described in this Agreement. This authorization is voluntary and may be revoked as set forth above.

I acknowledge receipt of the Notice of Privacy Practices and authorize SMS communications as described.

Authorization Term and Expiration

This Authorization shall remain in effect until the earlier of (a) Patient's revocation, or (b) the Authorization Expiration Date: . If left blank, the Authorization remains in effect until revoked.

Security, Liability and Indemnification

The Provider will implement reasonable administrative, technical, and physical safeguards to protect SMS content. To the fullest extent permitted by law, Provider's liability for any claim arising from SMS communications is limited to direct damages and shall not include consequential, incidental, or punitive damages. Patient agrees to indemnify and hold harmless Provider from claims arising from Patient's failure to follow instructions or to maintain privacy of their mobile device.

Modification, Assignment, Governing Law

This Agreement constitutes the entire understanding between the parties regarding SMS communications. Any modification must be in writing signed by both parties. The Provider may assign its rights and obligations under this Agreement in connection with a sale or transfer of its business. This Agreement is governed by the laws of the state where the Provider maintains its principal place of business, without regard to conflict of law principles.

Patient Certification

I certify that the information provided in this form is true and correct to the best of my knowledge, that I am the subscriber or authorized to consent on behalf of the subscriber for the mobile number provided, and that I have authority to grant this consent.

I certify the above statements and authorize SMS communications as indicated.

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