Patient Consent for Communication by Unsecured SMS (Template)

Purpose. This consent authorizes ShadowNurse, Inc. (“SN”) to send unencrypted SMS text messages, which may include limited Protected Health Information (PHI), to the patient at the mobile number provided.

1. Risks of SMS Communication

• Standard SMS is not encrypted; messages may be intercepted or viewed by unauthorized persons.

• Messages may remain on the device or carrier servers indefinitely.

• PHI contained in these messages could be exposed if the device is lost, stolen, or compromised.

2. Scope of Consent

I consent to receive unsecured SMS from SN for the purposes I check below (check all that apply):

☐ Appointment reminders and scheduling updates
☐ Care‑plan coordination or navigation services
☐ Wellness, behavior change, or chronic‑care support
☐ Information about community resources or services
☐ Other: ______________________________

Messages may include limited PHI, such as program names, general health topics, or limited references to conditions.

3. Patient Responsibilities

• Notify SN immediately if my number changes.

• Protect access to my device (e.g., passcode, biometrics).

• I may stop SMS at any time by replying STOP or contacting SN.

4. Voluntary Participation

• SMS consent is optional; declining will not affect my care or benefits.

• Alternative communication methods (secure portal, phone, email) are available on request.

Authorization and Signature

Printed Name: ___________________________
Date of Birth: ___________________________
Mobile Number: _________________________
Signature: ______________________________
Date: ___________

Internal Use
Consent recorded on: ___________
Recorded by (staff): ___________

A digital or facsimile copy of this consent is as valid as the original. This authorization may be revoked at any time by written notice to SN; revocation does not affect prior communications sent in reliance on this consent.