HIPAA consent forms.

I acknowledge that I have been provided with Cellebration’s “Notice of Privacy Practices,” and I am giving my consent for the use and disclosure of Protected Health Information as required and/or permitted by law.

Patient Name

(please print)

Patient Signature

(or legal representative; proof may be requested)

Date

This form is mandatory for all patients. A signed copy is retained in your patient record; you may request a copy at any time.

Purpose. This form is used to obtain your consent to communicate with you by email and/or mobile text messaging regarding your Protected Health Information. Cellebration offers patients the opportunity to communicate by email/mobile text messaging. Transmitting patient information by email/mobile text messaging has a number of risks that patients should consider before granting consent to use email/mobile text messaging for these purposes. Cellebration will use reasonable means to protect the security and confidentiality of email/mobile text messaging information sent and received. However, Cellebration cannot guarantee the security and confidentiality of email/mobile text messaging communication and will not be liable for inadvertent disclosure of confidential information.

Patient Acknowledgment & Agreement

I acknowledge that I have read and fully understand this consent form. I understand the risks associated with communication of email/mobile text messaging between Cellebration and me and consent to the conditions outlined herein. Any questions I may have had were answered.

My Consented Email Address

My Consented Mobile Number for Text Messaging

Patient Signature

Date

In Case of Emergency: Please call 911 or proceed to the nearest emergency room. Do not use email or text message for emergency communication.