SMS HIPAA Consent

Provides optional consent to receive unsecured SMS that may include limited PHI. Outlines risks, scope choices, how to revoke, and available secure alternatives.

(v2025-08-21)

Effective Date: August 21, 2025

Brief Summary:
Standard SMS is not encrypted and may be viewed by your carrier or others with access to your device. If you opt in, ShadowNurse (“SN”) may send unsecured text messages that could include limited PHI (e.g., program names, care‑plan coordination notes, scheduling details). Message frequency varies; message/data rates may apply. You can opt out anytime by replying STOP (reply HELP for help). Consent is voluntary and not required for care; secure alternatives are available.

This consent authorizes SN to use SMS solely for care‑related purposes described above; it does not authorize marketing (separate opt‑in required) and may be revoked at any time. See /sms-hipaa-consent for the full template.

Patient Consent for Communication by Unsecured Short Message Service (SMS)

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.

For support, contact us at any time via phone at (833) 2-SHADOW or email at hello+SMS@shadownurse.com.

3. Patient Responsibilities Notify SN immediately if my number changes. Protect access to my device (e.g., passcode, biometrics).

4. Voluntary Participation

  • Reply STOP to opt out; HELP for help. Message frequency varies. Message and data rates may apply.

  • 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.