Spectrum - Text Message Consent

I authorize the sending and receiving of information between you and the following phone numbers.

• Mental health related information
• Communicable diseases (including HIV/AIDS)
• Alcohol/drug abuse treatment
• Appointment date/time
• Other (as specified)

This information may be used for treatment, consultation, billing, claims, and payment purposes.

I understand that I can revoke this authorization at any time in writing.

I understand that my treatment or benefits will not depend on signing this authorization.

Information disclosed may no longer be protected by federal or state law.

Authorization duration:

• Indefinitely
• Until treatment is completed

Date *

Name *

Signature *