SMS Opt-In Authorization

Norbert Health Monitoring Notifications

This page is a public reference copy of the consent form template. Authorized physicians enrolled in the Norbert Health Monitoring Notifications SMS program review and sign this form during onboarding with a Norbert Health representative. The form is not signed through this website. Norbert Health, Inc. retains the signed form as the record of consent.

Norbert Health, Inc.
support@norberthealth.com

Recipient

Full name: ______________________________________________
Title / credentials: ______________________________________________
Facility / organization: ______________________________________________
Mobile number to be enrolled: ______________________________________________
Email: ______________________________________________

About the Norbert Health Monitoring Notifications program

Norbert Health, Inc. operates an SMS notification program that delivers transactional clinical notifications to authorized physicians regarding patients under their care.

Notifications may contain protected health information (PHI) about patients under the recipient's care — including patient name, location, measured value, and clinical threshold. SMS is delivered through commercial mobile networks; mobile carriers and recipient device manufacturers are not Business Associates under HIPAA, so recipients are responsible for safeguarding the device on which messages are received.

Required disclosures

Message frequency varies. Volume per recipient is typically very low.
Message and data rates may apply.
Reply STOP at any time to unsubscribe. After STOP, you will receive a confirmation message and no further notifications from this program.
Reply HELP at any time for support contact information.
For questions, contact support@norberthealth.com.
The full program terms are published at https://legal.norberthealth.com/sms-terms and the privacy notice at https://legal.norberthealth.com/privacy.

Acknowledgements and consent

By signing below, I:

Authorize Norbert Health, Inc. to enroll the mobile number listed above in the Norbert Health Monitoring Notifications SMS program;
Acknowledge that I have read and agree to the SMS Program Terms and Privacy Policy linked above;
Understand that notifications may contain protected health information (PHI);
Will safeguard the device on which I receive these notifications — including passcode or biometric lock — and will exercise reasonable judgment about message previews, message storage, and onward sharing;
Understand that mobile carriers and device manufacturers transmitting and storing these messages are not Business Associates under HIPAA;
Understand that I may opt out of the program at any time by replying STOP to any notification, with no effect on any other Norbert Health service I receive;
Confirm that this consent is voluntary and is not a condition of any unrelated service or agreement with Norbert Health.

Signature

Signature: ______________________________________________
Printed name: ______________________________________________
Date: ______________________________________________