Client Consent to Email PHI Text Message

You may give permission to Mental Health Specialty Group, P.A. (the “Company”) to communicate with you by unencrypted email and text message (also known as SMS). The primary purpose of these communications will be for Company to inform you of appointment schedules and reminders, to check in periodically, and to provide other information about services that you obtain from Company. This form provides information about the risks of these forms of communication, guidelines for email/text communication, and how we use email/text communication. It also will be used to document your consent for communication with you by email and text message.

1) Risk of using unencrypted email and text messages: The use of unencrypted email and text message has a number of risks that you should consider. These risks include, but are not limited to, the following:

a) Emails and texts can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients.

b) Senders can misaddress an email or text and send the information to an undesired recipient.

c) Backup copies of emails and texts may exist even after the sender and/or the recipient has deleted his or her copy.

d) Employers and on‐line services have a right to inspect emails and texts sent through their company systems.

e) Emails and texts can be intercepted, altered, forwarded or used without authorization or detection. f) Emails and texts can be obtained and used as evidence in court.

g) Cell phones and other personal devices containing emails and texts can be lost or stolen resulting in disclosure of messages to unauthorized individuals.

2) Conditions for the use of email and text messages: Company cannot guarantee but will use reasonable means to maintain security and confidentiality of email/text information sent and received. You must acknowledge and consent to the following conditions:

a) IN A MEDICAL EMERGENCY, DO NOT USE EMAIL, CALL 911. Do not use email/text for urgent problems. Please call your physician or 911 in the event of a medical emergency. Urgent messages or needs should be relayed to us by using regular telephone communication and may include text messages.

b) Emails/texts to us should not be time-sensitive. While we try to respond to email messages daily, we cannot guarantee that any particular email will be read and responded to within any particular period of time. If you have not heard back from us within three days, call our once to follow up if we have received your email.

c) You should speak with your Company representative to discuss complex and/or sensitive situations rather than send email or text messages regarding such situations.

d) You should use your best judgment when considering the use of email or text messages for communication of sensitive medical information. Company and its personnel are not responsible for the content of messages you sent to Company.

e) Company is not liable for breaches of confidentiality caused by you or any third party.

f) It is your responsibility to follow up with your Company representative if warranted.

3) Withdrawal of consent: I understand that I may revoke this consent at any time by so advising Company in writing. To withdraw consent to text messages, I can text STOP to (323) 205-7088. My revocation of consent will not impact my ability to obtain future health care nor will it cause the loss of any benefits to which I am otherwise entitled.

4) Patient Acknowledgement and Agreement:

I acknowledge and agree that by providing my cell phone number to Company I am consenting and agreeing to receive unencrypted email and/or text messages at the telephone number provided, and such messages may include information relating to my health and healthcare, including orders, appointment schedules and reminders, repairs, and other information about products and services that I order and obtain from Company.

I understand that message and data rates from my cell phone service provider may apply. To unsubscribe to text messages, text STOP to (323) 205-7088. For help text HELP anytime to (323) 205- 7088.

I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the use of unencrypted email and text messaging as a form of communication between Company and me, and consent to the conditions and instructions outlined, as well as any other instructions that Company may impose to communicate with me by email or text message.

Have questions? Email info@pathccm.com