EFTA00313915.pdf

ACULTY GROUP PRACTICE CELL PHONE CONTACT FORM NYU Langone Health I understand that as a service to its patients, NYU Lango ne (Faculty Group Practicel provides bill pay reminders to patients that may be placed using a prerec orded message or text message. 8y providing my cell phone number to NYU Langone and signin g below, I am giving consent to receive these calls or text messages at the number maint ained in my NYU Langone medical record. I understand that if my cell phone number is updat ed at NYU Langone, I will receive the calls or text messages to the new number, unless I have opted out as described below. I also understand that this consent will apply to any NYU Lango ne Faculty Group Practice office that may use this service. El I GIVE CONSENT for NYU Langone to contact me regarding bill pay reminders on my cell phone. ❑ I DENY CONSENT for NYU Langone to contact me regarding bill pay reminders on my cell phone. I understand that I can opt-out at any time by emailing my name and date of birth (for verification) to [email protected] submitting a message via MyChart, or by providing written notice to: NYU Langone Physician Servic es, PO Box 415662, Boston, MA 02241 Patient (Parent/Guardian) Signature Date EFTA00313915