PSYCHOTHERAPY PARTNERS AUTHORIZATION FOR ELECTRONIC COMMUNICATION
By signing this form I authorize Psychotherapy Partners, LLC to communicate with me electronically via telephone, email, faxing, the clinic website, internet patient portal, designated insurance and/or EAP websites, appointment scheduling sites claims filing sites. These communications will be used for scheduling, and also for collecting or sending pertinent clinical, insurance information and claims, billing &/or collections information as is necessary to provide your treatment and or to correspond.
I understand that communications via the means as described above are not always secure. Although it is unlikely, there is a possibility that information you or we send may intercept. Or it may also read by other parties besides the person to whom it is addressed.
Moreover, I understand that by federal law, Psychotherapy Partners, LLC may not use/disclose my healthcare information without my authorization except the information designated in my Patient-Clinician Agreement.
My signature on this disclosure indicates that I am giving my permission to engage in the electronic and internet communication described above. I hereby release Psychotherapy Partners, LLC, from any and all liability that may arise from the release of electronic information.
Right To Revoke
I understand that I have the right to revoke this authorization at any time. If I want to revoke this authorization I must do so in writing and address it to Psychotherapy Partners, LLC. Firstly, I understand that if I revoke this authorization, it will not apply to any information previously released as a result of this authorization. Secondly, I may refuse to sign this authorization. I also understand that Psychotherapy Partners, LLC cannot deny or refuse to provide treatment or billing services if I refuse to sign this authorization. I understand that once the information is disclosed pursuant to this authorization, it is possible. It will no longer protected by the federal medical privacy law. It then disclosed by the person or agency that receives it.
Disclaimer :
By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature I on this document.