This is the communication consent form practices using HyperClinic AI give to their patients. It is completed on paper or during check-in by the practice, under the practice's own name. HyperClinic AI does not obtain consent from patients directly, and nothing entered here is collected.
If you are a patient, your practice will give you their version. Questions about your care or your records go to your practice.
Practices should have this reviewed by their own counsel before use. It is offered as a starting point, not as legal advice.
Please read both sections and initial each one. You may accept or decline the communication methods below individually. · Form version 1.0 · A copy of this signed form is available to you on request.
You agree that this practice, and the software it uses to communicate with patients, may contact you at the phone number and email address you provide. Messages may include appointment reminders and confirmations, check-in links and intake forms, arrival and waiting-room updates, billing and payment notices, test-result notifications, and other messages about your care.
Message frequency varies with your appointments and care. Message and data rates may apply. Reply STOP to any text message to opt out at any time, and HELP for help. Opting out of text messages does not opt you out of phone calls or email; ask the front desk to change those.
Text messages and email are not fully secure. Someone with access to your phone or email account may be able to read them. Messages will be kept brief and will avoid clinical detail where possible, but some health information may appear.
Your treatment and all clinical services are provided by practice legal name and its licensed clinicians. That practice is responsible for your care and for your medical record.
HyperClinic AI LLC provides the software this practice uses for check-in, clinical documentation and patient communication. HyperClinic AI LLC does not provide medical care, does not make clinical decisions, and is not your healthcare provider. It handles your information only on the practice's instructions, as a business associate under a written HIPAA Business Associate Agreement, and it does not use your health information for its own purposes.
Questions about your care, your medical record, or your bill go to the practice. The practice's Notice of Privacy Practices describes how your health information is used and disclosed, and your rights over it.
Patient name (print) |
Date of birth |
Patient signature |
Date |
If signed by a personal representative — name and authority |
Date |