Consent for Use of Protected Health Information in Email, Texting and Voicemail

Email and text messaging allows health care providers to exchange information efficiently for the benefit of our clients. At the same time, we recognize that email and text messaging are not a completely secure means of communication because these messages can be addressed to the wrong person or accessed improperly while in storage or during transmission. Similarly, detailed voice mail messages allow clinicians to provide treatment related information to you in a timely manner but if the voice mail system is shared, the information could be heard by others.

If you would like us to send you email and/or text messages or leave detailed voicemails that contain your health information, please check the box above. You are not required to authorize the use of email, voice mail and/or text messaging and a decision not to sign this authorization will not affect your care in any way. If you prefer not to authorize the use of email, voice mail and/or text messaging we will continue to use U.S. Mail or telephone to communicate with you.

I authorize the use of text, voicemail and email as methods when communicating with me and my authorized individual at the number provided upon intake. I understand that I may elect out of this portion of the treatment agreement and that I may provide written notice to my counselor at any time and be offered an amended agreement upon request without the Consent for Use of Protected Health Information in Email, Texting and Voicemail.