HIPAA Privacy and Release of Information Authorization
I, ___________________________________ hereby authorize WOMEN'S+ HEALTH COLLECTIVE PLLC and its affiliates, its employees and agents, to use and disclose protected health information (e.g., information relating to the diagnosis, treatment, claims payment, and health care services provided or to be provided to me and which identifies my name, address, social security number, Member ID number) for the purpose of helping me to resolve claims and health benefit coverage issues.
I understand that any personal health information or other information released to the person or organization identified below may be subject to re-disclosure by such person/organization and may no longer be protected by applicable federal and state privacy laws.
I understand that I have a right to revoke this authorization by providing written notice. However, this authorization may not be revoked if its employees or agents have taken action on this authorization prior to receiving my written notice. I also understand that I have a right to have a copy of this authorization.
I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
I further understand that this authorization is voluntary and that I may select . My refusal to sign will not affect my eligibility for benefits or enrollment or payment for or coverage of services.
I have been advised of this practice’s Privacy Practices, Release of Billing Information policy, Assignment of Benefits policy, and grant the practice Medication History Authority.
If applicable, Legal Representatives sign below:
By signing this form, I represent that I am the legal representative of the Member identified above and will provide written proof (e.g., Power of Attorney, living will, guardianship papers, etc.) that I am legally authorized to act on the Member’s behalf with respect to this authorization form.
Please list any persons whom you authorize us to discuss or release medical information and /or test results with:
(Authorizations will remain in effect for 1 year from Authorization date unless change is requested in writing)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
By checking this box, I certify that no one is authorized to receive my medical information.
Signature: __________________________________________________________ Date: _______________
Patient Text Messaging Terms and Conditions
Women’s Health Collective provides SMS text messaging to patients who choose to receive text messages from our office.
1. Consent to Receive SMS Messages
By providing your mobile phone number and opting in to receive text messages from Women’s Health Collective, you consent to receive SMS messages from us regarding healthcare-related and administrative matters.
Messages may include, but are not limited to:
Scheduling and rescheduling appointments
Billing and payment-related communications
Requests for information or follow-up
Other healthcare-related or administrative communications from our office
Your consent to receive SMS messages is not a condition of receiving medical care or purchasing services from Women’s Health Collective.
Message frequency may vary.
2. Message and Data Rates
Message and data rates may apply depending on your mobile phone plan and carrier. Women’s Health Collective is not responsible for charges imposed by your wireless carrier.
3. Opting In
You may opt in to receive SMS messages by providing your mobile phone number and completing the applicable consent or enrollment process provided by Women’s Health Collective.
By opting in, you acknowledge that you have provided consent to receive SMS messages from Women’s Health Collective at the mobile number provided.
You are responsible for ensuring that the mobile phone number you provide is accurate and belongs to you or that you are authorized to use that number.
4. Opting Out
You may withdraw your consent and opt out of SMS messages at any time by replying STOP to any text message from Women’s Health Collective.
After receiving your opt-out request, we will send a confirmation message and will cease sending SMS messages to that number, except for communications that may be necessary to process your opt-out request or as otherwise permitted by applicable law.
Please understand that opting out of SMS messages is only for direct communication with our staff. Receiving appointment reminders, and balance notifications through text messaging is a separate system.
5. Help and Support
For assistance with our SMS messaging program, reply HELP to any message from Women’s Health Collective.
You may also contact our office directly for assistance with text messaging or other communication options.
6. SMS Privacy and No-Sharing Policy
Women’s Health Collective respects the privacy of information associated with your participation in our SMS messaging program.
We will not sell, rent, or share your mobile phone number, SMS opt-in information, or SMS consent data with third parties or affiliates for their own marketing or promotional purposes.
SMS opt-in data and consent information will not be shared with any third parties or affiliates for marketing or promotional purposes. This includes the transfer, sale, rental, or disclosure of SMS opt-in information to third parties or affiliates for their own advertising, marketing, or promotional activities.
Your SMS opt-in data and consent records will be used only as reasonably necessary to administer and provide the SMS messaging service, comply with applicable legal requirements, maintain records of consent, and communicate with you as authorized by your consent.
We do not sell or provide SMS opt-in data to data brokers or marketing databases.
7. Information Included in Text Messages
Text messages may contain information related to your healthcare, appointments, billing, or other administrative matters.
SMS messaging is not considered a completely secure method of communication. Text messages and notifications may potentially be viewed by anyone who has access to your mobile phone or associated notifications.
HIPAA Privacy and Release of Information Authorization
I, ___________________________________ hereby authorize WOMEN'S+ HEALTH COLLECTIVE PLLC and its affiliates, its employees and agents, to use and disclose protected health information (e.g., information relating to the diagnosis, treatment, claims payment, and health care services provided or to be provided to me and which identifies my name, address, social security number, Member ID number) for the purpose of helping me to resolve claims and health benefit coverage issues.
I understand that any personal health information or other information released to the person or organization identified below may be subject to re-disclosure by such person/organization and may no longer be protected by applicable federal and state privacy laws.
I understand that I have a right to revoke this authorization by providing written notice. However, this authorization may not be revoked if its employees or agents have taken action on this authorization prior to receiving my written notice. I also understand that I have a right to have a copy of this authorization.
I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
I further understand that this authorization is voluntary and that I may select . My refusal to sign will not affect my eligibility for benefits or enrollment or payment for or coverage of services.
I have been advised of this practice’s Privacy Practices, Release of Billing Information policy, Assignment of Benefits policy, and grant the practice Medication History Authority.
If applicable, Legal Representatives sign below:
By signing this form, I represent that I am the legal representative of the Member identified above and will provide written proof (e.g., Power of Attorney, living will, guardianship papers, etc.) that I am legally authorized to act on the Member’s behalf with respect to this authorization form.
Please list any persons whom you authorize us to discuss or release medical information and /or test results with:
(Authorizations will remain in effect for 1 year from Authorization date unless change is requested in writing)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
By checking this box, I certify that no one is authorized to receive my medical information.
Signature: __________________________________________________________ Date: _______________