The consent form examples included in this toolkit draw on similar content areas, but differ in the amount of text and literacy level of explanation of consent. When designing your consent forms you should be aware of the basic literacy level of your patient population and tailor your consent to fit your patient’s needs. Using the examples below, feel free to mix and match different components to your system’s and patient population’s specific needs as well as your system’s HIPAA requirements. Systems may interpret HIPAA in different ways requiring varying levels of consent.
Some systems preferred to have patients ‘opt-out’ rather than ‘opt-in’. Systems would text patients without explicit prior consent and offer them the ability to opt-out of further text messages by replying with a request to stop the messages.
Other systems opted patients in and collected their information for text messaging along with the patient’s clinical intake forms. Below is a diagram depicting the spectrum of consent processes employed by CCI grantees.
Generally you’ll want to address the following items in your consent form:
- Statement that the patient agrees to receive the text message service
- Explanation of service – what the text messages will be for
- Explanation of benefit – how the patient will potentially benefit from the text message service
- Address potential risks, especially related to the potential of lost privacy/Protected Health Information (PHI) if the patient’s phone is lost or someone else accesses their phone
- Disclaimer of potential cost to the patient if their cell phone carrier charges them per text message
- How to opt out / cancel service
- Language preference if offering in multiple languages
- Patient’s cell phone number
- Patients name and signature
Please find examples below from both within and outside of CCI’s Texting for Better Care program:
- Simple Consent to Receive Text Messages – This form is very simple, about half a page, with single sentence and bullet point explanations for each consent item. It only requires the patient’s name, signature and date.
- Blood Pressure Texting Program Consent Form – This form provides a basic template for texting consent developed by Northeast Valley Health Corporation, it is one page and relatively simply written. Text is in paragraph form. This consent also requires a witness signature from Health System staff.
- Obstetrics Patient Consent for Patient Relationship Management – This is a comprehensive consent form covering all areas addressed above in detail. It is text heavy, but well organized.
- Postcard Patient Consent and Sign-up Form – This consent developed by San Francisco General Health Plan is in the form of a postcard which would be mailed out to patients. It is simple and concise allowing patients to opt in by filling out the form on the postcard and returning it by mail.
- HIPAA Consent for Purposes of Treatment, Payment, and Health Care Operations (English / Spanish) – This consent developed by Golden Valley Health Centers includes language about texting and other electronic communication such as email and phone.
- Comprehensive text messaging consent form as part of research study – This is a 5 page consent designed for a clinical study utilizing text messages at Olive View-UCLA Medical Center and other major medical universities. While it is comprehensive, it requires a high level of literacy and a considerable time investment to read through, comprehend, and sign.
- Substance Abuse Recovery Texting Program Consent Form – This is a simple sign-up form developed by Sacramento Native American Health Center that collects basic contact information and reasons for declining.
- Consent to Receive Text Alerts (English / Spanish) – This is another simple sign-up form similar to above developed by Petaluma Health Center that collects basic contact information and reasons for declining.
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