Who we are
Our website address is: https://pieferboneandjoint.com.
Piefer Bone and Joint, along with its affiliates, agents, independent contractors, and any “covered entity” or “business associate” (as defined under the HIPAA Privacy Rule) with which your information may be shared under HIPAA (collectively, “Piefer Bone and Joint”), may communicate with you via email, text message, and/or other forms of unencrypted electronic communication (together, “Electronic Messaging”) using the telephone number(s), email address(es), or other contact information associated with your account or provided below. This form explains Piefer Bone and Joint’s use, the risks involved, and the conditions of Electronic Messaging. It also serves to document your consent for Piefer Bone and Joint to communicate with you through these methods.
Patient Acknowledgment and Agreement
I have read and fully understand this consent form. I acknowledge the risks associated with the use of Electronic Messaging between Piefer Bone and Joint and myself. I consent to the conditions and instructions outlined, as well as any other instructions that Piefer Bone and Joint may impose for communication by Electronic Messaging.
I understand that Piefer Bone and Joint will send Electronic Messaging to the telephone number(s) and email address(es) in my account:
☐ I request to receive text messages
☐ I request to receive email messages
Release
In consideration of Piefer Bone and Joint’s services and my request to receive Electronic Messaging as described herein, I hereby release Piefer Bone and Joint, located at 3786 FM 1488 Road, Suite 300, Conroe, TX 77384 (phone: 346-497-6502), from any and all claims, causes of action, lawsuits, injuries, damages, losses, liabilities, or other harms arising from or related to these communications. This includes, but is not limited to, claims, causes of action, or lawsuits based on alleged violations of laws such as:
- The Telephone Consumer Protection Act
- The Truth in Caller ID Act
- The CAN-SPAM Act
- The Fair Debt Collection Practices Act
- The Fair Credit Reporting Act
- The Health Insurance Portability and Accountability Act
- Any similar state and local acts or statutes
- Any federal or state tort or consumer protection laws
I understand that Piefer Bone and Joint will send Electronic Messaging to the telephone number(s) and email address(es) in my account:
☐ I request to receive text messages
☐ I request to receive email messages
By checking the boxes, I confirm that I have reviewed and understand the risks and conditions of Electronic Messaging and consent to these communications.
Contact Us
For questions or concerns about this Privacy Statement, contact us:
Phone: 281-374-2273
Mail: 1441 Woodstead Court, Suite 300, The Woodlands, TX 77380