Consent to Receive Mobile Phone Text Messages

(This is a copy the consent form signed electronically by BCOM patients via our electronic health record system)

By providing you rmobile phone number and email address to Broward Community & Family Health Centers, Inc. (“BCOM”), you are agreeing to be contacted by or on behalf of BCOM and its business partners, identified below, including emails to your email address and text (SMS) messages to your mobile phone and other wireless devices,
and the use of an automatic telephone dialing system, artificial voice and pre-recorded messages,for the purpose of providing tele-appointment services offered by the BCOM and its businesspartners.

Providing an email address is necessary to receive tele-appointment services from BCOM. You may opt-out of receiving text (SMS) messages from BCOM or its business partners at any time by replying with the word STOP from the mobile device receiving the messages. You do not need to provide this consent for text (SMS)messages to receive any services from BCOM.However, you acknowledge that opting-out of receiving text (SMS) messages may impact your experience with the service(s) that rely on communications via text (SMS) messaging. I can withdraw my consent for receiving text (SMS) messages from BCOM at any time by contacting our administrative staff.

If you wish to receive text message updates regarding the care of your family member/friend, please read and sign the following consent:

• I understand texting over mobile/cell phones carries security risks because text messages to mobile/cell phones are not encrypted. This means that information you receive by text message could be intercepted or viewed by an unintended recipient, or by your mobile/cell phone provider or carrier.

• I understand that I am responsible for all fees charged by my carrier’s service plan for text messaging. Partners HealthCare and affiliates are not responsible for any increased charges, data usage against plan limits or changes to data fees I may be charged from text messaging.

• I understand that I may decide to opt out of this texting program at any time by replying by text “STOP”.

• I understand it is my responsibility to update my mobile/cell phone number that is listed below.

___ YES – to receive mobile phone text message and email notifications

___ NO – to NOT receive mobile phone text message (email notifications only)

Patient Signature

Electronic Signature

Patient/Guarantor’s Signature (electronic) Date and Witness Signature (electronic)