Accepted Therapy

Non-Secure Release

Consent for Release of Protected Health Information by Non-Secure Means

Date of Birth:

I authorize Accepted Therapy Services to transmit to me by non-secure media the following types of protected health information related to my health records and health care treatment:

Information related to the scheduling of meetings or other appointments.

Information related to billing and payment

I understand that if I contact my therapist through non-secure means (text messages, email, or other phone apps) my therapist reserves the right to not respond to protect my confidentiality.

Consent for Release of Protected Health Information by Non-Secure Means

Termination of Consent