Patient Consent for Communications

STEADFAST HEALTH
PATIENT CONSENT FOR COMMUNICATIONS

Phone Calls and Text Messages

CONSENT FOR HEALTHCARE CALLS AND TEXT MESSAGES

Mobile telephone number: (____) ____ – ______________________________
Healthcare calls or text messages. I give consent and authorize Steadfast Health to deliver healthcare calls or text messages — including those made using an automated system or prerecorded and/or artificial voice messages — to the telephone number I provide above. These messages relate to patient outreach, care coordination, appointment scheduling, and follow-up communications. I understand that consent is not required as a condition of receiving any services or treatment.

IMPORTANT INFORMATION
Message Frequency: Varies based on your care needs and appointments.
Rates: Message and data rates may apply.

To Unsubscribe: Reply STOP to these messages at any time to unsubscribe.

For Assistance: Reply HELP for assistance.

Privacy: Steadfast Health will not share your mobile opt-in information with third parties for marketing
purposes.

For details on how we handle your information, see our Privacy Policy (https://steadfasthealth.com/privacypolicy/) and Terms & Conditions (https://steadfasthealth.com/terms-conditions/).

CONSENT ELECTIONS
Please indicate your choice for each communication type by initialing the line you select. Consent is voluntary and
is not required to receive services or treatment.

Healthcare Calls. YES — I consent to receive healthcare phone calls from
Steadfast Health at the number above.

Initials: __________
Healthcare Text Messages. YES — I consent to receive healthcare text
messages from Steadfast Health at the number above.

Initials: __________
If you do not initial a line above, you will not be enrolled in that communication type.

ACKNOWLEDGMENT AND SIGNATURE
By signing below, I acknowledge that I have read and understood the above consent, that my questions have
been answered, and that I am signing this form voluntarily. I understand that I may withdraw this consent at any
time by contacting Steadfast Health.
Patient / Authorized Representative Signature Date
Printed Name Relationship to Patient (if applicable)
This form is protected under HIPAA and 42 CFR Part 2. Do not disclose to unauthorized parties.