Client Consent to Allow PHI by Email or Text Message

Please complete this form to the best of your ability.

Client Consent to Allow PHI by Email or Text Message

You may give permission to Trinity Psych Wellness (TPW) to communicate with you by unencrypted email and/or by text messages (not including other messaging such as WhatsApp, FaceBook Messenger, etc.). The primary purpose of these communications will be to allow us to inform you of appointment schedules and changes, provide other service-related information, and to give you another option for communicating similar information.

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 and will be uploaded to your medical record with TPW.

1. Risk of using unencrypted email and text messages: The use of unencrypted email and text messaging has several 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 accidentally send or forward an email or text to an undesired recipient.
c. Backup copies of emails and texts may exist even after the sender and/or recipient has deleted their copy.
d. Employers and online 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: TPW cannot guarantee but will use all 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 OR TEXT, CALL 911. Do not use email/text for urgent problems. Please call your physician or 911 in the event of an emergency or go to your closest ER. Urgent messages 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 email will be read and responded to within any particular period of time. If you have not heard back from us within three business days, call us once to follow up if we have received your email.
c. Any complex or sensitive information should be discussed with your provider, the Director, or the Office Manager rather than sending it as email or text message.
d. You should use your best judgment when considering the use of email or text messages for communication of sensitive medical information. TPW and its personnel are not responsible for the content of messages you send.
e. TPW is not responsible for breaches of confidentiality caused by you or any third party.
f. It is your responsibility to follow up with your therapist or medication prescriber if warranted.
g. Please be aware that message and data rates from your cell phone service provider may apply.

3. Withdrawal of consent: You may revoke this consent at any time by advising TPW in writing.
a. To withdraw consent for text messages, please email your provider or drop off a written note.
b. To unsubscribe from email messages, please bring or send a written note to that effect.
c. Your revocation of consent will not impact your ability to obtain future health care, nor will it cause any loss of any service benefits. You may reinstate it any time.

Patient Acknowledgement and Agreement

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

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 TPW and me, and consent to the conditions and instructions outlined, as well as any other instructions that TPW may impose to communicate with me by email or text message.

Client Consent to Allow PHI by Email or Text Message


Client Consent to Allow Personal Health Information (PHI) by Email or Text Message

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