HIPAA COMMUNICATION AUTHORIZATION

Client Name: __________________________________________

Please mark each method you request we use and each method you do not want us to use for communication of your protected health information. 

I have been notified that there is some level of risk that protected health information transmitted by unencrypted video conferencing could be seen by someone other than me.  

☐ Yes – Communicate with me by Google Hangout 

☐No – Do not communicate with me by Google Hangout   

I have been notified that there is some level of risk that protected health information transmitted by unencrypted email could be read by someone other than me.

☐ Yes – Communicate with me by Email (Personal Communication & Monthly Newsletters)

☐No – Do not communicate with me by unencrypted email  

I have been notified that there is some level of risk that protected health information transmitted by text could be read by someone other than me.

☐ Yes – Communicate with me by Text (Personal Communication)

☐No – Do not communicate with me by text 

Signature:______________________________________                         Date:_______________________

Expiration Date: none

You have the right to revoke this authorization at any time by contacting me by email at caitlynedsonrd@gmail.com

%d bloggers like this: