Patient Electronic Communication Consent

Sign Up for Electronic Communications from AcariaHealth

Electronic communications with AcariaHealth includes text messages. Electronic communications containing PHI (protected health information) between AcariaHealth and the patient/authorized representative may be used if you, the patient/authorized representative, agree to this method and complete the sections below. This agreement is limited to communications related to program benefits or services using the phone number you authorize below. You can change or withdraw your authorization any time by contacting us or following the opt out steps outlined in the received text messages. This completed agreement replaces any prior agreement effective the date it is received.

First Name *

Last Name *

Cell Number *

I have read and understand the Electronic Communications Agreement

Provider Awareness:

Standard email and text are not a secure means of communication. As your healthcare provider, AcariaHealth will use the minimum necessary amount of protected health information when responding to your questions or communicating information to you. Unsecure electronic communications will not include highly sensitive PHI (such as information relating to mental health or substance abuse).

Patient Awareness:

Standard email and text do not provide a secure means of communication. There is some risk that PHI within the unsecure electronic communication may be disclosed to, or intercepted by, unauthorized third parties. Use of more secure communications, such as phone or fax, are always available alternative methods of communication with AcariaHealth.

Text messages originating from AcariaHealth will indicate that AcariaHealth sent the message.