Patient Text Message Consent Form
Families Matter Therapies
Purpose of Communication
By signing this form, I authorize [Practice Name] to send me text messages (SMS) to my mobile number for purposes related to my care, including appointment reminders, treatment updates, preventive health notifications, billing information, and follow‑up care.
Potential Risks (please review)
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Text messages are not completely secure—they can be intercepted, forwarded, or accessed by unintended parties.
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My mobile provider may charge for messages or data.
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Copies may remain stored even after deletion, and messages can be used as legal documentation.
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- If privacy is critical, I acknowledge that secure patient portals or encrypted messaging may be safer.
Use of a HIPAA‑Compliant Service
[Practice Name] will use a secure, HIPAA‑compliant texting platform—encrypted and monitored under a Business Associate Agreement—to safeguard my Protected Health Information (PHI) when communicated.
Consent and Acknowledgment
☐ I confirm the following:
1. I have read and understand the above information and container of risks, as well as my rights under HIPAA.
2. I explicitly consent to receive non‑urgent health-related texts at the number below.
3. I understand that urgent issues should not be communicated via text. I will contact the office by phone or emergency services.
4. I may withdraw consent at any time, without affecting my care, by contacting [Practice Contact] in writing.
Patient Information
Name:
DOB:
Mobile Number for Texts:
Signature:
Date:
If you do not wish to receive text messages, please check here: ☐
OFFICE USE ONLY
Date Consent Received:
Staff Name/Title: