Text message consent

The text-message preference is written on clinical form CF-003, Rev. 1.0, of Orlando Foot Care Nurse LLC. The form title is: HIPAA Privacy Acknowledgment, Patient Communication Authorization, and Authorization for Release of Protected Health Information (PHI).

This example is the blank form. The lines for patient name, date of birth, signature, date, and relationship to the patient are empty. No communication preference is selected.

Under Patient Communication Authorization, the Communication Preferences include this option:

Send appointment reminders by text message.

That line is one preference on the list. On the blank form it is not selected. The same list has separate unchecked options to leave detailed voicemail messages, leave appointment reminder messages, send appointment reminders by email, discuss care with a caregiver, discuss care with a legal representative or Power of Attorney, discuss care with facility staff directly involved in the patient's care, and not leave voicemail messages.

Under Patient Acknowledgment, the form says that by signing, the person acknowledges this:

I authorize the communication preferences selected above.

A signature on CF-003 authorizes the communication preferences selected on that form. This blank example has no signature and no selected preference.

The public website does not display the CF-003 form. This page describes the blank form.

CF-003 does not name a text-message company. It does not state how often messages are sent, whether message or data rates apply, or the words STOP or HELP.