Member Consent Form

Manage your communication consent preferences securely and in accordance with applicable regulations.

By submitting this form, you authorize Guidehealth to contact you through the methods selected below for purposes including care updates, appointment reminders, billing notices, and health education. This consent is voluntary and does not affect your eligibility for benefits or services.

For phone and SMS, you consent to receive calls or texts, including automated messages, under the Telephone Consumer Protection Act (TCPA). Message and data rates may apply. Text STOP to cancel.

You may withdraw consent at any time by resubmitting this form. Your information is handled in accordance with our Privacy Policy and applicable law, including the Health Insurance Portability and Accountability Act (HIPAA).

Member Information

Member / Card ID * Member / Card ID is required.

First Name * First name is required.

Middle Initial

Last Name * Last name is required.

Date of Birth * Date of birth is required.

Consent Preferences

For each communication method below, please indicate your preference and provide contact details if applicable.

Your personal information is collected and used solely to administer your communication preferences. For full details, please review our Privacy Policy. By submitting this form, you acknowledge that you have read and understood our Privacy Policy.

I have read and agree to the Privacy Policy * You must acknowledge the Privacy Policy to continue.

Electronic Signature

By typing your full name below, you acknowledge that you have read and understand this consent form, and agree that your typed name constitutes a legally binding electronic signature.

Full Name * Electronic signature is required.

Member Consent Form

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