Pleasant Valley Health Services offers text messaging as a convenient way to communicate with patients regarding their care and administrative needs. Text messaging may be used for:

• Appointment reminders
• Appointment confirmations
• Scheduling, rescheduling, or cancellation of appointments
• Medication refill reminders
• Customer care and support communications
• Administrative notifications related to services
• Requests for information related to your care

Text messaging is provided as a convenience and should not be relied upon for urgent or emergency communications.

Text messaging carries certain risks that patients should understand before consenting to this method of communication.

I understand that:

• Text messages are not always secure or encrypted.
• Messages may be viewed by unauthorized individuals who have access to my phone or mobile device.
• Mobile devices may be lost, stolen, shared, or accessed by others.
• Text messages may be delayed, misdirected, intercepted, or not delivered.
• Cellular carriers and technology systems may experience service interruptions.
• Pleasant Valley Health Services cannot guarantee that every text message will be received, read, or responded to.
• Communication through text messaging may involve the disclosure of protected health information (PHI), including appointment information and information related to my treatment.

I acknowledge these risks and voluntarily consent to communicate through text messaging.

Text messaging may be used for:

• Appointment scheduling and reminders
• Administrative communications
• Medication refill reminders
• Customer service and support
• General practice-related communications

Text messaging is not intended for:

• Medical emergencies
• Psychiatric emergencies
• Crisis intervention
• Time-sensitive clinical concerns
• Detailed treatment discussions

Pleasant Valley Health Services may determine that certain matters require communication through telephone, telehealth, secure messaging, or an in-person visit rather than text messaging.

I understand that text messaging is not monitored continuously and should never be used for emergencies.

If I experience:

• Thoughts of suicide or self-harm
• Thoughts of harming another person
• A psychiatric emergency
• A medical emergency
• Any urgent health concern

I agree to:

• Call 911 immediately;
• Go to the nearest emergency room; or
• Contact the 988 Suicide & Crisis Lifeline by calling or texting 988.

I understand that Pleasant Valley Health Services cannot guarantee immediate review or response to text messages.

I understand and agree that:

• Sending a text message does not guarantee receipt by Pleasant Valley Health Services.
• Staff may not be immediately available to respond.
• Responses may be delayed due to clinical responsibilities, office closures, technical issues, device malfunction, carrier interruptions, or other circumstances.
• The only confirmation that a text message has been received is a response from Pleasant Valley Health Services.

By providing my mobile phone number and checking the consent box below, I authorize Pleasant Valley Health Services to send me text messages regarding:

☐ Appointment reminders

☐ Appointment confirmations

☐ Scheduling, rescheduling, and cancellations

☐ Medication refill reminders

☐ Customer care and support communications

☐ Administrative notifications related to my care

I understand that:

• Message frequency may vary.
• Message and data rates may apply.
• Consent is not a condition of receiving healthcare services.
• I may opt out at any time by replying STOP.
• I may obtain assistance by replying HELP.

I may withdraw my consent at any time by:

• Replying STOP to any text message; or
• Providing written notice to Pleasant Valley Health Services.

Upon opting out, I will receive a confirmation message and no additional text messages will be sent unless I provide new consent.

Pleasant Valley Health Services respects and protects patient privacy in accordance with applicable federal and state laws, including HIPAA.

We use reasonable safeguards to protect personal information; however, text messaging is not a fully secure form of communication.

SMS consent and phone numbers collected for SMS communications are not shared with third parties or affiliates for marketing purposes.

Pleasant Valley Health Services does not sell, rent, lease, distribute, or otherwise disclose mobile phone numbers to third parties for their marketing purposes.

We may utilize secure vendors and communication service providers to facilitate messaging services on our behalf. These vendors are contractually obligated to maintain the confidentiality and security of patient information and may only use such information to provide services to Pleasant Valley Health Services.

Mobile opt-in information will never be shared, sold, rented, or disclosed to third parties or affiliates for marketing or promotional purposes.

I understand that Pleasant Valley Health Services is not responsible for any charges incurred from my wireless carrier, including:

• Text messaging fees
• Data usage fees
• Roaming charges
• Other carrier-related charges

I agree to notify Pleasant Valley Health Services promptly if:

• My mobile phone number changes;
• My device is lost or stolen; or
• I no longer wish to receive text communications.

This authorization shall remain in effect until revoked by me in writing or by replying STOP to text communications.

For assistance, reply HELP, call 571-569-0607, email support@pleasantvalleymentalhealth.com, or visit pleasantvalleymentalhealth.com.