Omaha Childrens Clinic Communication Consent

Telephone Messages

As parent/guardian, I give Omaha Childrens Clinic permission to leave relevant, detailed telephone messages regarding my child(ren)’s care and follow up, including test results, on my answering machine when I am not available at the following phone numbers provided:

Primary #

Secondary #

Cell #

I do NOT give Omaha Childrens Clinic permission to leave detailed telephone messages regarding my child (ren)’s care when I am unavailable. I will return the phone call.

Patient Portal: The patient portal is an optional service that allows parents/guardians to retrieve selected patient information and communicate directly with our staff. If you are interested in adding this feature for your family, please read the following information and sign this form, giving us consent to activate a portal for you.

We do not sell or give away any protected health or contact information. We reserve the right to suspend or terminate the Patient Portal account at any time and for any reason without notice.
Please note that the Patient Portal is not checked for messages on weekends or holidays.
By using the Patient Portal, you agree to protect your password from unauthorized individuals. It is your responsibility to notify us if your password gets lost or stolen, we will reactivate a new account for you.
You agree to not hold OCC responsible for any network infractions beyond our control.

As parent/guardian, I consent to activating a Patient Portal for my child(ren).

Email Address

Text Appointment Reminders: This is an automated text reminder of your child’s appointment 1-3 days in advance. This feature would replace the reminder calls you now receive. We require one cell phone number on file to enable this feature.

As parent/guardian, I give Omaha Childrens Clinic permission to text me appointment reminders regarding my child (ren)’s scheduled appointments.

Same as above

Cell #

I do NOT give Omaha Childrens Clinic permission to text me appointment reminders. I prefer to be contacted by telephone.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

I understand that this authorization for disclosure is in effect until I choose to have it revoked, and I may do so at any time.

Your information will be encrypted.