By signing and submitting this form, you are agreeing to the following acknowledgment:
My clinician and/or other employees of Atlanta Psychological Services may contact me using the electronic contact information I entered above.
My clinician and APS employees will limit their disclosure of my medical information and Protected Health Information (PHI) when communicating with me indirectly (via phone or otherwise).
I understand that I am responsible for the device or platform I use in communicating electronically with APS employees and my clinician. I know that I should communicate only on a device that I know is safe and technologically secure (e.g., has a firewall, anti-virus software installed, is password-protected, not accessing the internet through a public wireless network, etc.).
If an email address is provided above, or if you provided one to this office for communicating with you, you give APS employees and your clinician permission to contact you at that email address.
Our email platform is hosted by Google Suites with Paubox Encryption, which meets federal standards for protecting medical information and is HIPAA compatible. A Business Associate Agreement (BAA) has been signed with both companies, meaning they have attested to HIPAA compliance and assume responsibility for keeping your medical information secure.
If email is authorized, we encourage you to also use encrypted email for protection on your end (several options are available at www.TeleHealth.org). Otherwise, when you reply to one of your clinician's emails, everything you write in addition to what he/she has written to you (unless you remove it) will no longer be secure. Our encrypted email service only works to send information and does not govern what happens on your end.
For evaluation reports, providing your email address allows you to receive the report as soon as possible.
I understand that if I (or my child) am experiencing an emergency situation and need to contact someone immediately to help, I will call any of the emergency numbers that are listed on the consent for treatment form. If you are in a crisis, please do not communicate this to us via email or electronic means because we may not receive it in a timely matter.
I understand that I can revoke or amend this agreement at any time.
Any revocation or change will not apply to communications already completed.