Consent to Leave Voice or Text Messages

Consent to Leave Voice or Text Messages

Completion of this document authorizes the disclosure and/or use of health information about you. The purpose is to permit you to leave certain health information on your voice or text messaging service. Failure to provide all information requested may invalidate this authorization.

I hereby authorize Pecan Tree Family Dentistry to call or text the following telephone numbers:

And leave detailed voice or text messages with the following information:

• Details about my next appointment (provider name, date/time, and callback number)
• Test and other exam results
• Account payments, balances, or cost estimates
• Only the following types of health information (including any dates)
• I DECLINE. Please do NOT leave any voice or text messages.

I may refuse to sign this authorization. My refusal will not affect my ability to obtain treatment payment or eligibility for benefits. If the health information is being disclosed or used, I may inspect or obtain a copy of this health information. I may revoke this authorization at any time, but I must do so in writing and submit it to the

following address:     Pecan Tree Family Dentistry, 2315 Virginia Parkway, McKinney, Texas 75071               

                                                                                           (Name and address of practice)

My revocation will take effect upon receipt, except to the extent that others have acted in reliance upon this authorization. I have the right to receive a copy of this authorization. Information disclosed according to this authorization could be re-disclosed by the recipient. Such re-disclosure is in some cases not protected by state law and may no longer be protected by federal confidentiality law (HIPAA).