Email Authorization

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Email Authorization

Email *

I authorize the Center for Therapy & Counseling Services, LLC, and its employed and contracted licensed health care providers and staff (collectively, "The Center"), to use email to communicate clinical information to me pertaining to mental health care services that I may receive from The Center. I acknowledge and understand that the most secure method of communication is by telephone call; however, if I choose to communicate with The Center by email, these communications may contain my personal and private medical information (including, but not limited to, my name, address, date of birth, types and dates of mental health care services received, medications, insurance coverage information, and/or test results). *

I understand the above.

I understand that although The Center will take reasonable measures to attempt to protect the privacy of the contents of emails sent to me; the emails sent to me travel over the Internet. As a result, there is a risk that emails may be intercepted and read by unauthorized third parties. By choosing to communicate with The Center via email, I assume this risk. *

I understand the above.

I acknowledge and understand the following as it relates to email communications:

1. Email is not appropriate for conveying information relating to urgent or emergency medical matters. If I am experiencing an urgent or emergency situation, I understand that I should dial 911 immediately. *

I understand the above.

2. If an email has not been answered within twenty-four (24) hours, I should call to make sure that it has been received and I may make an appointment to discuss the email. *

I understand the above.

3. I will not use email communications for discussion of sensitive or highly confidential issues. If there are specific types of information that I do not want included in emails, it is my responsibility to notify The Center. *

I understand the above.

4. Certain other health care providers who are permitted access to my medical records (such as consulting health care providers) may have access to my email address and email message. *

I understand the above.

5. I, and not The Center, am responsible for the security of emails sent from or stored on my computer, tablet, or phone. *

I understand the above.

6. My decision to allow The Center to communicate with me by email is voluntary, and treatment is not conditioned upon my election to do so. *

I understand the above.

7. The Center or I may stop email communications at any time for any reason. *

I understand the above.

8. I agree to notify The Center when my email address changes. *

I understand the above.

9. I will not to hold The Center responsible for damages resulting from its use of email or the failure of any of The Center's information systems to facilitate email communications. *

I understand the above.

10. I understand that all emails related to my care, received or generated by The Center, may be maintained in my medical record. *

I understand the above.

The Center may send clinical information to me by email at the following email address: *

The Practice may also communicate via email with the designated individual listed below:

Name:

Relationship to patient:

Email address:

By typing your name below, you are stating you understand the information included in this form. Type name below. *

Date *

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