BLUE RIDGE BEHAVIORAL HEALTH
170 Thomas Johnson Drive, Suite 200, Frederick, MD 21702
Phone: 301-695-8390

CONSENT TO USE EMAIL AND TELEPHONE COMMUNICATION

• I understand that any email or phone communication with administrative staff at Blue Ridge Behavioral Health (BRBH) is used solely for administrative purposes.
• I understand that email communication is used by the administrative staff at BRBH to send and exchange correspondence and forms only. It is not to be used for any clinical issues, scheduling appointments, prescription requests or billing inquiries.
• I understand that the use of email and phone communication with clinicians at BRBH will vary based on the provider. Specifically, email communication with clinicians is permitted only with the approval of individual providers. Patients understand that not all clinicians will agree to the use of email with patients or their parents/guardians.
• I understand that the use of email and phone communication with clinicians at BRBH is restricted only to scheduling appointments, providing appointment reminders, and addressing clinical concerns.
• I understand that administrative staff and clinicians at BRBH will respond to email and phone messages within 24 hours during regular business hours, Monday through Friday from 8:30am until 4:30pm, excluding weekends and holidays. Some clinicians may elect to respond outside of regular business hours, but this will be at the sole discretion of the specific provider.
• I understand that email and phone messages are not monitored after regular business hours.
• I understand that if I change my email address or my phone number, it is my responsibility to inform the administrative staff at BRBH.
• I understand that all emails will become part of my permanent record.
• I understand that there are risks in using email to communicate with BRBH. These risks may include but are not limited to confidential information being seen by others. While BRBH makes every effort to keep information secure, BRBH cannot guarantee that electronic communication is 100% safe and protected. I understand that I am entering into electronic communication with full knowledge of the risks therein.
• I understand that if I fail to maintain the security of and/or restrict access to my email, and information is seen by others, BRBH is not in violation of the Health Insurance Portability and Accountability Act (HIPAA). If I fail to maintain the security of and/or restrict access to my email, and information is seen by others, I hereby release BRBH from all liability.

By signing below, I authorize Blue Ridge Behavioral Health to use my email address and telephone number for the purposes outlined above. I understand that I may cancel this authorization at any time by providing Blue Ridge Behavioral Health with written communication that includes the date that my authorization is withdrawn.