Acknowledgement and Consent

Welcome
Welcome

As part of our commitment to quality and service, we request authorization to communicate regarding cases using the methods and communication channels selected and approved by our customers.

While we offer secure messaging that meets all HIPPA requirements through our patient portal, we understand other convenient communication methods may be preferred. Cottonwood Labs will communicate any way the customer requests, however, Cottonwood Labs does not gurantee other communication methods meet HIPPAA-requirements.

By providing thia information, you ( the authorized representative) acknowledge and accept the potential privacy risks associated with non-secure communication methods and voluntarily reuest their use, if selected
Communication Method Options
Customer Name (Authorized Representative)*
Customer Email (Authorized Representative) *
Authorized Representative Phone Number *
Customer Number (if Known)
Please approve communication methods*

Cottonwood Labs Secure Patient PortalPhone CallEmailWhatsApp MessagingConventional Text MessagingLoom Video RecordingdZoon Video Conferencing with Fathom Notetaker
If you selected WhatsApp, SMS, Email, or Zoom, how should we refer to cases?*

Use Cottonwood Labs Case Number Only (recommended for PrivacyUse Patient NameUse Both Case Number and Patient Name
Acknowledgement and Consent*

I am the authorized representative for this customer, practice, and / or doctorI understand that some of the communication methods 've selected may not fully secure or meet all HIPAA-requirementsI accept the associated risks and request that these methods be used for communication regarding case(s)I understand that Zoom meeting may be recorded and transcribed using Fathom Notetaker for confidential documentation purposesI may update or revoke this permission at any time by notifying Cottonwood Labs in writing
Should be Empty:

Welcome

Communication Method Options