Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.
You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.
By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
The Patient understands that:
Protected health information may be disclosed or used for treatment, payment or health care operations.
The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice.
The Practice reserves the right to change the Notice of Privacy Practices.
The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions.
The patient may revoke this Consent in writing at any time and all future disclosures will then cease.
The Practice may condition receipt of treatment upon the execution of this Consent.
Information collected from the patient (including mobile information) will NOT be sold or disclosed to any third parties for marketing/promotional purposes.
Patient information (including mobile information) is given voluntarily by the patient (including name, phone number, email address, etc.). This information will ONLY be used to discuss healthcare and treatment options specific to the patient’s concern. Patient may opt out of any form of communication at any time by texting or emailing STOP and/or discussing in person in the office.
SMS Terms and Conditions:
By providing your mobile phone number, you consent to receive SMS messages from Rocky Mountain Wellness Center related to appointment reminders, account status/inquiry, satisfaction, and/or Q&A. Message frequency may vary. Standard message and data rates may apply.
You may opt out of receiving SMS messages at any time by replying with "STOP" to any SMS message you receive from us. After opting out, you will receive a confirmation message, and we will cease sending SMS messages to your number.
If you need assistance or have questions about our SMS service, reply with "HELP" to any SMS message you receive, or contact our customer support team at 801-683-9553 or drgreenstaff@myutahwellness.com
Privacy Policy
Your phone number will be handled in accordance with our Privacy Policy, available at https://myutahwellness.com/privacy-policy-1. No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.