"*" indicates required fields PATIENT AUTHORIZED COMMUNICATIONPatient Name:* First Last Parent/Guardian First and Last Name (if patient under 18 years old): Spouse/Other: First and Last Name: Current Mobile Phone Number(s):*Current Mobile Phone Number(s):Current Email Address:* Current Email Address #2: Patient hereby authorize Provider to leave Protected Heath Information (“PHI”) pertaining to Patient’s care by voicemail/email/text and will assume responsibility to notify them whenever this information changes. Patient authorizesProvider to leave messages with the person(s) Patient has designated as Patient’s approved contacts or emergency contacts. Patient understands that PHI used or disclosed pursuant to this Authorization may be subject to re-disclosure bythe recipient and no longer protected by Federal or State Law. Patient understands that Patient have the right to revokethis authorization at any time. Patient understands that in order to revoke this authorization, Patient must do so inwriting and present Patient’s revocation to Provider. Patient understands that the revocation will not apply to information that has already been used or disclosed in response to this authorization. Patient understands that this authorization isvalid unless and until written notice is provided to revoke this authorization. Patient understands that Provider cannot require Patient to sign this authorization as a condition of treatment unless the provision of health care by Provider is for the sole purpose of creating PHI for disclosure to a third party legally authorized to receive such information. By providing a telephone number, Patient expressly consent and authorize SIS, any practitioner or clinical provider as well as any of their related entities, agents, or contractors including but not limited to schedulers, debt collectors, and other contracted staff (collectively referred to herein as “Provider”) to contact Patient through the use of text messages and any dialing equipment (including a dialer, automatic telephone dial system, and/or interactive voice recognition system) and/or artificial or prerecorded voice or message. Patient expressly agree that such automated calls and/or text messages may be made to any telephone number (including numbers assigned to any cellular or other service for which Patient may be charged for the call) used by or associated with Patient and obtained through any source including but not limited to any number Patient is providing today, have provided previously, or may provide in the future in connection with the medical goods and services and/or Patient’s account. By providing this express consent, Patient specifically waives any claim Patient may have to the making of such calls, including any claims under the federal or state law and specifically any claim under the Telephone Consumer Protection Act, 47 U.S.C. § 227. By providing a telephone number, Patient represent that Patient is the subscriber or owner or have the authority to use and provider consent to call the number. By providing Patient’s email address now or at any time in the future in connection with the medical goods and services provided and/or Patient’s account, Patient expressly opt-in to the receipt of email communications from Provider for or related to the medical goods or services provided, Patient’s account, and other services such as financial, clinical, and education information including news, changes to health care laws, health coverage, care follow-up, and other health care opportunities, goods, and services. By providing this express consent, Patient specifically waives any claim PATIENT may have for the sending of such emails, including any claim under federal or state law and any claim under the CAN-SPAM Act, 15 U.S.C. § 7701, et. seq. By providing an email address, Patient represents that Patient is the subscriber or owner of have the authority to use and provider consent to contact the email address. Patient understands that providing a telephone and/or email address is not a condition of receiving medical services. Patientunderstands that Patient may revoke Patient’s consent to contact at any time by directly contacting Provider or using the opt-out method that will be identified in the applicable communication. Patient also understands that it is Patient’s responsibility to notify Provider immediately of any change in telephone number or email address.Patient Name:* First Last Date* MM slash DD slash YYYY Patient/Patient Representative Signature :*Relationship to Patient: Reason Patient is Unable to Sign: Patient/Patient Representative Signature :Allow for other individuals to access information as designated by the patient.