Consent for Use of Electronic Communication

I consent to the use of electronic communications to enable Northwestern Mental Health Center (NWMHC), Inc. to deliver services and communicate with me. Communication types include telephone, texting, e-mail, and online communication and are compliant with privacy regulations.

Appointment Reminders and Provider Cancellations
I also understand NWMHC’s policies allow NWMHC to contact its clients to remind them of appointments. I understand NWMHC’s automated appointment reminder system allows for me to RSVP my appointment and that I can select “confirm”, “reschedule” or “cancel”. If I choose “cancel” my appointment will be canceled and I am responsible to call to reschedule if desired. If I choose “reschedule” NWMHC staff will follow up with me to reschedule. NWMHC will notify me of agency closures or provider cancellations via this automated system. I understand the automated system does not accept additional text messages from me. By my consent below, I authorize NWMHC to employ a third-party automated outreach and messaging system to use my personal information, the name of my care provider, the time and place of my scheduled appointment(s) and other limited information, for the purpose of notifying me of a pending appointment, a missed appointment or any other healthcare-related function. I consent to receive multiple messages per day from NWMHC, when necessary. I consent to allow detailed messages being left on my voice mail, answering system, or with another individual if I am unavailable at the number provided by me.

Appointment Follow Up: Reschedules and Missed Appointments
I understand NWMHC will follow up with me regarding requests to reschedule my appointments as well as in regard to missed appointments. This followup may be via telephone, e-mail or text. This followup system allows for two-way text communication and my responses will be monitored by staff reaching out to me.

Telemedicine Appointments
For telemedicine, I understand my telemedicine appointment may be held with me via an electronic device in my possession (i.e. smartphone, tablet or laptop).

I do hereby waive, release and discharge NWMHC, Inc, its officers, employees and all others from any and all responsibilities or liability from unintentional exposure of my identity and/or communications.

I understand I may revoke this consent (not retroactively) at any time and will do so in writing by completing a new authorization form. If my telephone or e-mail changes, I am responsible to notify NWMHC.

I consent to the use of e-mail communications. *

Yes No

Email address *

I consent to the use of text messaging communications. *

Yes No

I consent to receive electronic appointment reminders. *

Yes No

Client Information

Legal Name *

First Name Last Name

Preferred Name

First Name Last Name

Date of Birth *

Please indicate your relationship *

Self Parent Legal Guardian Conservator Health Care Agent / Health Care Power of Attorney

Parent Name *

First Name Last Name

Name of Legal Guardian *

First Name Last Name

Name of Conservator Health Care Agent / Health Care Power of Attorney *

First Name Last Name

My signature indicates that I am legally authorized to sign on behalf of the client.

Signature *

Clear

Date *