Consent for PHI Storage and Electronic Signatures

Authorization and Consent for PHI Storage and Use of Electronic Signatures
Why This Authorization is Necessary?

At Silver Home Care, we prioritize protecting your personal information, including any Protected Health Information (PHI) you provide to us. To deliver the best possible care and streamline our processes, we use Google Workspace, a HIPAA-compliant cloud platform, for secure data storage.

This system ensures that your information is handled in compliance with strict privacy and security standards, safeguarded under a Business Associate Agreement (BAA) with Google Workspace. Additionally, using electronic signatures allows us to efficiently and securely manage your forms and authorizations, in line with legal requirements.

By completing this authorization, you help us maintain a secure, efficient process for storing and handling your information while ensuring compliance with applicable laws and regulations. If you have any concerns or do not consent, you can opt out and contact us for alternative methods to complete your intake process.

Authorization Terms
1. Consent for PHI Storage: By completing this form and providing your information, you consent to Silver Home Care storing your data, including PHI, on this secure platform.
2. Consent for Electronic Signatures: By signing this document electronically, you agree that your electronic signature is legally binding and carries the same validity as a physical signature. This process complies with the Electronic Signatures in Global and National Commerce Act (E-SIGN) and the Uniform Electronic Transactions Act (UETA
3. Opt-Out Instructions: If you do not consent to the storage of your information on this platform or to the use of electronic signatures, please exit this form immediately and contact Silver Home Care directly to discuss alternative methods for completing the intake process. Do not complete or submit any further forms.
Client Name*
Date

MonthDayYear
Date
Representative Name
Relationship (if Representative)
Email*
example@example.com
Client/Representative Signature*

Clear
Please provide the email address where you would like to receive all documents and communications. You will receive an email from us with detailed instructions and a secure code to access your documents.*
Client ID
Should be Empty:

Authorization and Consent for PHI Storage and Use of Electronic Signatures