Consent for Communication

Clients frequently request that we communicate with them by phone, voicemail, email or text. Rocky Mountain TheraPros respects your right to confidential communications about your protected health information (PHI) as well as your right to direct how those communications occur.   Since email and texting can be inherently insecure as a method of communication, we will only communicate with you by email or text with your written consent at the email address or phone number you provide to us below. Please be aware that if you have an email account through your employer, your employer may have access to your email. 

When you consent to communicating with us by email or text you are consenting to email and texting communications that may not be encrypted.  As well voicemail or answering machine messages may be intercepted by others. Therefore, you are agreeing to accept the risk that your protected health information may be intercepted by persons not authorized to receive such information when you consent to communicating with us through phone, voicemail, email or text. Rocky Mountain TheraPros will not be responsible for any privacy or security breaches that may occur through voicemail, email or text communications that you have consented to. 

You may choose to limit the type of voicemail, email or text communication you have with us if you wish to limit your risk of exposing your protected health information to unauthorized persons. Please indicate below what types of correspondence you consent to receive by email or text.

	▫	I do not consent to any voicemail, email or texting communication. 
	▫	I consent to receiving communication about the scheduling of appointments or other communications that do not reveal my protected health information only by the following means (check all that you consent to):
o	Email
o	Text
o	voicemail
	▫	I consent to all communication, including but not limited to communication about my medical condition and advice from my health care providers by the following means (check all that you consent to):
o	Email
o	Text
o	voicemail   

E-mail address you are consenting to communicate through: ____________________________

Phone number you are consenting to communicate through:___________________________

Patient	Signature:  _________________________________________Date_______________

Authorized Rep/Guardian Signature:____________________________Date_______________