Authorization for Release of Information
I hereby authorize Boulder Mind Care to obtain from any source and examine and use, or discuss and disclose and provide any information necessary regarding the patient with health care practitioners involved in the care of the patient. These communications of information may involve unencrypted electronic communications by email, phone, text messages, and voicemail as well as fax. These communications may include protected health information and other confidential information. This authorization to obtain and release information is valid until revoked. The undersigned may revoke this consent in writing at any time, except with regard to information that has already been shared or disclosures that have already been made in reliance on such consent.
Electronic Communications Authorization
I hereby authorize Boulder Mind Care to communicate with me using electronic communications including email, text messages, and voicemail. I may be contacted using the numbers or addresses that I have provided to Boulder Mind Care, or that I have used to initiate contact with Boulder Mind Care. These communications may include appointment information, as well as protected health information and confidential information. I understand that these electronic communications are not encrypted.
Acknowledgment of Privacy Practices Notice
I have reviewed the Notice of Privacy Practices at
Financial & Appointment Policies/Agreement to Pay
I have reviewed and agree to the Boulder Mind Care's policies regarding appointment scheduling and payment at
I understand that I am directly responsible for all charges incurred for medical services for the patient.