Patient Messaging (SMS)
Informed Consent Form

PATIENT'S AUTHORIZATION - This form authorizes Mountain Medical Practice to communicate with you via text messaging including SMS (Short Message Service) that allows sending short text messages and MMS (Multimedia Messaging Service) that allows sending multimedia content like images, videos, and audio, along with text for certain non-urgent healthcare-related purposes. With your consent, Mountain Medical Practice may use text messaging to send the following types of communications: • Appointment reminders • Prescription notifications • General information • Seasonal promotions • Special updates. Our office uses a HIPAA-compliant communication platform through a VOIP (Voice over Internet Protocol) service provider with privacy safeguards in place, including privacy and security business agreements with technology vendors in accordance with federal regulations. Your Rights and Responsibilities include the following: • SECURITY & PRIVACY: Although our VOIP carrier provides HIPAA-compliant messaging and encryption safeguards under our privacy and security business agreements, no form of electronic communication can be guaranteed to be 100% secure. By consenting, you acknowledge and accept this minimal risk. • NOT FOR EMERGENCIES: Text messaging should not be used for urgent or emergency medical situations. Please call 911 or go to the nearest emergency room for immediate care. • HELP OPTION: You may get help with messaging at any time by replying “HELP” to a message or contacting our office at (775) 849-3000. • OPT-OUT OPTION: You may revoke your consent to receive text messages at any time by replying “STOP” to a message or contacting our office at (775) 849-3000. • CARRIER CHARGES: Standard message and data rates may apply depending on your mobile service provider.

ACKNOWLEDGEMENT & CONSENT - By checking the box above, you confirm the following: 1. You have read and understood this consent form, 2. You voluntarily consent to receive text messages from Mountain Medical Practice using our HIPAA-compliant VOIP messaging system, 3. You understand that message frequency may vary and that message and data rates may apply, 4. You understand that you may revoke this consent at any time, 5. You acknowledge the potential risks of electronic communication and accept them, 6. You have read and agree to the SMS Privacy Policy and Terms & Conditions.