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I authorize the hospital and all clinical providers who have provided care or interpreted my tests, along with any billing service and their collection agency or attorney who may work on their behalf, to contact me on my cell phone and/or home phone using pre-recorded messages, artificial voice messages, automatic telephone dialing devices or other computer-assisted technology, or by electronic mail, text messaging or by any other form of electronic communication.

Why do we ask for Date of Birth?

Protecting your private health information is our utmost concern. In order to authenticate your account and conform to HIPAA (Health Insurance Portability and Accountability Act of 1996) security standards, we require two forms of identification. HIPAA is United States legislation that provides data privacy and security provisions for safeguarding medical information.

Thank you for your interest in paperless statements. As a Oklahoma Heart patient/guarantor, you have the right to have the statements for the accounts you have at Oklahoma Heart provided or made available to you through one of the following methods free of charge: paper via postal delivery or electronically through an online service. At any time you may withdraw this request to have your statements made available online (in lieu of mailed paper statements) by un-checking the opt-in box. If you change your e-mail address, please update it in the edit profile section of this site.

To reach Customer Service with regard to any questions about this consent form and the consent process, please call 888-400-5724

By checking the Receive electronic Statements box, I acknowledge that I have read, understand, and agree to this consent form. I hereby request that you make my account statements available for all accounts except those in collections I have at Oklahoma Heart via online service rather than postal mail each time such document would be sent to me via postal mail. Please continue to do so until I withdraw this request as described above.

I understand that the software I must have to view this document via online banking is Adobe Acrobat. (You will need Adobe Acrobat Reader to view the document. If you do not have Adobe you can click here to download a free copy of it.) I hereby represent to you that I have the required hardware and software and am able to access. Oklahoma Heart may change the hardware and software required at any time on 45 days' advance notice. If I choose not to obtain the new hardware or software, I may withdraw my request for e-statements without any fee or charge by you for such withdrawal.

By submitting this form I agree to all of the statements outlined above.