FHCCGLA Patient Communications Consent
I [esiggravity formid=”4″ field_id=”1″ display=”value” ], understand that Family Health Care Centers of Greater Los Angeles, Inc. (FHCCGLA)uses a commutative system in which I maybe contacted via phone call, video call, email, patient portal or text message, to notify me of my appointments and coordinate my overall healthcare needs. I acknowledge that it is my responsibility to inform the staff at FHCCGLAshould any of my contact information change, including but not limited to my contact information, my name, address, email, phone number and emergency contact. I agree to notify FHCCGLA at my earliest convenience.
I understand that I have the option to stop reminders by text message at any time by responding with OPT_OUT in the text response. I understand that I have the option to modify this consent form at any time. I am aware that there is a level of risk with unencrypted emails and text messages where information could be read by someone else besides me.
Agreeing to the Patient Communications Consent Form means I am complying with the protection of my personal health information under The Health Insurance Portability and Accountability Act of 1996 (HIPAA).
I exercise my right to decline or accept unencrypted text messages and email through the Telephone Consumer Protection Act of 1991 (TCPA).
Please communicate with me via:[esiggravity formid=”4″ field_id=”6″ display=”value” ]
I understand that by supplying my home phone/mobile phone number, email address, and any other personal contact information, FHCCGLA may use an auto-dialer and/or third-party automated outreach and messaging system for the purpose of notifying me of an upcoming event, pending or missed appointment, important clinic information or other forms of communication.
Third-Party Ride ShareNotice to Patient/Service User:
I acknowledge that FHCCGLA may, at its discretion, offer to provide transportation services through a third-party rideshare services (Uber/Lyft/Taxi). The service is provided to patients that have no transportation to get to or from appointments. I understand that if the transportation service is provided to me, Family Health Care Centers of Los Angeles, Inc.is not liable for ANY SITUATION resulting in an accident, injury, theft, or other matter after I have gotten in the vehicle. I understand that Family Health Care Centers of Greater Los Angeles, Inc.is not associated in any way with Uber, Lyft, or the taxi service. In the event that transportation is arranged for me via Uber/Lyft, I acknowledge that if I do not cancel 24-hours before my scheduled ride, I will be charged a minimum of $10.00.
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Document Name: FHCCGLA Patient Communications Consent
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