Customer Email / Texting Informed Consent Form

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Please review the agreement below and then scroll to bottom to fill in and sign.  Thank you!

You may give permission to WABASHA COUNTY SOCIAL SERVICES' staff to communicate with you by email and text message. This form provides information about the risks of these forms of communications, guidelines for email/text communication, and how we use email and text communications. It also will be used to document your consent for communication with you by email and text message.

 

How we will use email and text messaging: We use these methods to communicate only about non-sensitive and non-urgent issues. All communications to or from you may be made a part of your human services record. You have the same right of access to such communications as you do to the remainder of your record. Your email and text messages may be forwarded to another WABASHA COUNTY SOCIAL SERVICES member as necessary for appropriate handling. We will not disclose your emails or text messages to third parties or others unless allowed by state or federal law. Please refer to your Notice of Privacy Practices for information as to permit uses of your information and your rights regarding privacy matters.

 

Risk of using email and text messages: The use of 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 onpaper, and broadcast to unintended recipients.

b. Senders can easily 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 used as evidence in court.

g. Email and text messaging may not be secure, and therefore it is possible that a third party may breach the confidentiality of such communications.

 

Conditions for the use of email and text messages: Wabasha County Social Services cannot guarantee but will use reasonable means to maintain security and confidentiality of email/text information sent and received. You as the Customers/Parents/Lega Guardians must acknowledge and consent to the following conditions:

a. IN AN EMERGENCY, DO NOT SEND an EMAIL or TEXT to WABASHA COUNTY SOCIAL SERVICES; PLEASE CALL or TEXT 911. Do not email or text for urgent problems. If you have an urgent problem during regular business hours, please call our agency at (651) 565-3351. Urgent messages or needs should be relayed to us by using regular telephone

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

c. You should speak with our agency to discuss complex and/or sensitive situations rather than send email or text messages regarding such situations.

d. Email and text messages may be filed electronically into your caserecord.

e. WABASHA COUNTY SOCIAL SERVICES staff will not forward your identifiable email/texts to outside parties without your written consent, except as authorized by law.

f. You should use your best judgment when considering the use of email or text messages for communication of sensitive information.

g. WABASHA COUNTY SOCIAL SERVICES staff are not responsible for the content of messages or any costs associated with messages.

h. WABASHA COUNTY SOCIAL SERVICES is not liable for breaches of confidentiality caused by you or any third party. 

i. It is your responsibility to follow up with your staff person if warranted.

j. It is your responsibility for charges your phone plan may have for texts.

 

Withdrawal of Consent: I understand that I may revoke this consent at any time by so advising WABASHA COUNTY SOCIAL SERVICES in writing. My revocation of consent will not affect my ability to obtain future services nor will it cause the loss of any benefits to which I am otherwise entitled.

 

Customer, Parent and/or Legal Guardian Acknowledgement and Agreement

 

I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the use of email and text messaging as a form of communication between WABASHA COUNTY SOCIAL SERVICES staff and me, and consent to the conditions and instructions outlined, as well as any other instructions that WABASHA COUNTY SOCIAL SERVICES may impose to communicate with me by email or text Iconsent to receiving appointment reminders and other communications/information, email and/or text from WABASHA COUNTY SOCIAL SERVICES.

I consent to receive text messages at my cell phone and any number forwarded or transferred to that number.  The cell phone number that I authorize to receive text messages for appointment reminders, feedback and general reminders/information is:    

I consent to emails, to receive communications as stated above. The email that I authorize to receive email messages for appointment reminders and general reminders/feedback/information is:    

I understand that this request to receive emails and/or text messages will apply to all future appointment reminders/feedback/health information unless I request a change in writing.

For accessible formats of this information or assistance with additional equal access to human services, write to DHS.info@state.mn.us, call 800-657-3739, or use your preferred relay.