Specialty Benchmarks LLC

Patient Satisfaction Survey Text Messages
Consent Form & Program Terms

How patients opt in to receive our survey text messages, and what those messages contain.

Specialty Benchmarks LLC is an anesthesia quality benchmarking company. On behalf of the hospitals and surgery centers we serve, we send a short patient satisfaction survey by text message after a patient's anesthesia care.

Opt-in method: written (paper) consent only. No consent is collected verbally, digitally, or by inbound message. Every patient who receives a text message from this program has signed the consent form reproduced below as part of the registration and intake paperwork at their treating facility.

The consent form patients sign

The block below is reproduced exactly as it appears on the registration form. A printable copy is available here: Patient SMS Consent Form (printable).

Patient Satisfaction Survey — Text Message Consent (Optional)

Facility:

Patient mobile phone number:

YES — I agree to receive survey text messages. By signing this form and providing my mobile phone number, I agree to receive SMS patient satisfaction survey messages (customer care and survey/polling messages) from Specialty Benchmarks LLC on behalf of the facility named above. I will receive up to 2 messages per visit. Message frequency may vary. Message and data rates may apply. Reply STOP to opt out at any time, or reply HELP for help. Consent is not a condition of treatment, purchase, or any service. My mobile information and my consent to this text message program will not be sold or shared with any third party for promotional or marketing purposes. See the Specialty Benchmarks LLC privacy policy at www.specialtybenchmarks.com/Home/Privacy.

Patient (or authorized representative) signature:

Printed name: Date:

Messages the patient receives

The first message a patient receives confirms the consent they gave at registration and carries the survey link. At most one reminder follows, using the same wording, and only if the survey has not been completed. Facility name and survey link are filled in per patient.

Confirmation message (first message sent, and reminder)

[Facility]: You agreed at registration to receive survey texts from Specialty Benchmarks. Take our 1-min anesthesia survey: https://survey.specialtybenchmarks.com/s/xxxxxxxx Msg freq varies. Msg&data rates may apply. Reply HELP for help, STOP to opt out.

Keyword replies

HELP → Specialty Benchmarks patient survey. Msg freq may vary. Msg & data rates may apply. Reply STOP to cancel. Help: 1-207-688-8486 or customerservice@specialtybenchmarks.com

STOP → You have been unsubscribed from Specialty Benchmarks survey messages and will receive no further texts.

Program terms

Brand / sender	Specialty Benchmarks LLC, 17 Campground Lane, Oxford, ME 04270
Program	Anesthesia patient satisfaction survey (customer care; polling and voting)
Who receives messages	Only patients who signed the written consent form above at their treating facility
Message frequency	Up to 2 messages per visit (one invitation, at most one reminder). Frequency may vary.
Cost	Message and data rates may apply. The survey itself is free.
Opt out	Reply STOP to any message. You may also use the opt-out link on the survey page.
Help	Reply HELP, call 1-207-688-8486, or email customerservice@specialtybenchmarks.com
Privacy	www.specialtybenchmarks.com/Home/Privacy — mobile information and SMS consent are never sold or shared with third parties for promotional or marketing purposes.
Marketing	This program sends survey messages only. No marketing or promotional messages are sent.