Client Record Request Unencrypted Disclaimer Form

Client Record Request Unencrypted Disclaimer Form
Disclaimer regarding less secure means of communication

I hereby grant permission to BHAVA Therapy Group to email or text me by unencrypted means. Unencrypted means sent without a passcode, which is less secure than the communication would be if it were it encrypted, that is, sent with a passcode. I have been informed by the practice of the risks, including but not limited to loss of confidentiality, of transmitting my protected health information by unsecured means. I understand that I am not required to sign this agreement in order to receive services from the practice. I also understand that I may terminate this authorization at any time in writing to the extent that the practice has not already relied upon it. I understand that the practice makes available to me the other means of communication that are designed to be more secure and to maintain confidentiality, and I still choose to request and authorize the above-named less secure means; other more secure means include phone calls, regular mail, (and encrypted email.)
Phone number where I am agreeing to receive unencrypted messages:
Please enter a valid phone number.
Email address where I am agreeing to receive unencrypted messages:
example@example.com
By signing below I am stating that I have read, understood, and agreed to the above mentioned terms and consitions:*

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