Healthcare Stability IVR Form

HEALTHCARE STABILITY IVR FORM

Patient Information

Date of Birth:    Gender:

Insurance Information

Medical History

IVR Stability Assessment

Assessment Date:

Housing stability: Stable Temporary Unstable

Access to prescribed medications: Yes Intermittent No

Reliable transportation to appointments: Yes No

Food security: Secure Insecure

Primary caregiver or social support available: Yes No

Patient at risk of missed appointments or treatment non-adherence: Yes No

Contact Preferences and IVR Consent

Preferred contact method (select all that apply): Phone call Text message Automated IVR call Email

Consent to automated outreach: I authorize the healthcare provider and its authorized agents to contact me using automated telephonic or electronic systems (including prerecorded messages, automated IVR calls, and text messages) at the contact numbers and email addresses provided for purposes related to care coordination, appointment reminders, medication adherence, care team outreach, and health-related notifications. I understand that consent is voluntary and that this authorization is not a condition of receiving treatment.

I consent to automated IVR, prerecorded calls, and text messages as described above.

I authorize the use of voicemail messages when necessary: Yes No

Privacy, Authorization, and Rights

Privacy and limited disclosure: I understand that information shared through IVR interactions may include limited health information necessary to facilitate care coordination. The provider will safeguard protected health information in accordance with applicable privacy laws. Information may be disclosed to contracted vendors who operate communication platforms for the provider; such vendors are bound by confidentiality obligations and permitted to use the information only to perform these services.

Right to withdraw: I understand that I may revoke or modify this consent at any time by notifying the healthcare provider in writing or by contacting the provider by telephone. Revocation will not affect actions already taken in reliance on this authorization prior to receipt of written notice of revocation.

Authorization duration: This authorization for IVR and automated contact shall remain in effect until the expiration date indicated below or until revoked in writing, whichever occurs first.

Certification: By signing below I certify that the information provided on this form is complete and accurate to the best of my knowledge. I understand the nature and purpose of the IVR and automated contact authorization, the types of messages that may be delivered, and the limits of confidentiality when messages are left on shared devices or voicemail.

I also acknowledge that IVR outreach is intended for non-emergent communications and that in the event of a medical emergency I should seek immediate emergency care.

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