Authorization to Contact. I authorize PHW personnel to communicate by mail, answering machine messages, and/or e-mail according to the information provided in my patient registration information. PHW or any agent of my patient account, may use any information I have provided, including contact information, e-mail addresses, cell phone numbers, and land line numbers, to contact me for purposes related to my account, including debt collection. I authorize PHW to use this information in any manner consistent with the information I have provided, including mail, telephone calls, e-mails, or text messages. I expressly consent to any such contact being made by the most efficient technology available, including automatic dialing/e- mailing or similar equipment, or pre-recorded or other messages, even if I am charged for the contact.
Authorization to Contact. I grant permission and consent to Provider and its agents, assignees, and contractors (which may include third party debt collectors for past due obligations): (1) to contact me by phone at any number associated with me, if provided by me or another person on my behalf; (2) to leave messages for me and include in any such messages amounts owed by me; (3) to send me text message or emails using any email address I provided or any phone number associated with me, if provided by me or another person on my behalf; and (4) to use prerecorded/artificial voice messages and/or an automated telephone dialing system (an auto dialer) as defined by the Telephone Consumer Protection Act in connection with any communications made to me as provided herein or any related scheduled services and my account and understand this contact may result in charges to me. I further agree to provide updated contact information to avoid unintended disclosures of my information and I accept and acknowledge that [healthcare facility name] and its agents, assignees and contractors (which may include third party debt collectors for past due obligations) will treat any email address or phone number I provide as my private email or phone number that is not accessible by unauthorized third parties. I understand that communication attempts will be made to my cellular phone during permitted calling hours based upon the time zone affiliated with the cellular phone number provided, unless notified otherwise. I understand that my refusal to provide the information described in this paragraph will not affect, directly or indirectly, my right to receive healthcare services.
Authorization to Contact. You authorize Northpoint and its employees, affiliates, agents, servicers, collection agencies and others calling at their request or on their behalf to contact you by mail, email, text message or telephone call at any address, email or telephone number (i) you have provided to us (ii) from which you have called us, or (iii) which we obtain and believe we can reach you at. We may contact you in any way, such as calling, texting, using an automated dialer or using pre-recorded messages. We may contact you on a mobile, wireless, or similar device, even if you are charged for it by your provider.
Authorization to Contact. You authorize personnel of this office to communicate by mail, answering machine messages, and/or e-mail according to the information provided in your patient registration information. Connecticut Colon & Rectal Surgery, LLC or any agent or servicer of your patient account, may use any information you have provided, including contact information, e-mail addresses, cell phone numbers, and landline numbers to contact you for purposes related to your account, including debt collection. You authorize us to use this information in any manner consistent with the information you have provided, including mail, telephone calls, e-mails, or text messages. You expressly consent to any such contact being made by the most efficient technology available, including automatic dialing/e- mailing or similar equipment, or pre-recorded or other messages, even if you are charged for the contact.
Authorization to Contact. I authorize CWH personnel to communicate with me by mail, answering machine messages, and/or e-mail according to the information provided in my patient registration information and my patient portal setting preferences. CWH, or any agent or servicer of my patient account, may use any information I have provided, including contact information, e-mail addresses, cell phone numbers, and landline numbers, to contact me for purposes related to my health and my account, including debt collection. I authorize CWH to use this information in any manner consistent with the information I have provided, including mail, telephone calls, e-mails, or text messages. I expressly consent to any such contact being made by the most efficient technology available, including automatic dialing/e-mailing or similar equipment, or pre-recorded or other messages.
Authorization to Contact. I hereby authorize Xxxxx X. Xxxxxxxx, MD and any of her representatives or staff to contact me by the methods listed here. Our practice may use or disclose the patients PHI to contact you by phone, voice mail, email, text. _X Signature of patient (or guardian if under 18 yrs old) DATE 5. RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT: I acknowledge that I have received, or have been offered a copy, of the Windhaven Adolescent and Sports Medicine Notice of Privacy Practices. (initial) OR I have DECLINED to receive the Notice of Privacy Practices offered by Windhaven Adolescent and Sports Medicine. I understand that I do not have to sign the acknowledgment in order for me/the patient to receive treatment by Windhaven Adolescent and Sports Medicine. (initial) _X Signature of patient (or guardian if under 18 yrs old) DATE
Authorization to Contact. Sponsor/Exhibitor acknowledges that the Event Organizer shall be permitted to share Sponsor/Exhibitor’s name and contact information with, and Sponsor/Exhibitor consents to being contacted directly by, vendors, sponsors, exhibitors and partners authorized by the Event Organizer as well as attendees of the Event.
