Today's Date
*
/
Month
/
Day
Year
Date Picker Icon
Full Name
*
First Name
Last Name
I consent to allow Vitalitas and its staff to use unsecured email, text, or other means of unsecured electronic communication to transmit to me the following protected health information:
*
Information related to the scheduling of meetings or other appointments
Information related to billing and payment
Completed forms, including forms that may contain sensitive, confidential information
Information of a therapeutic or clinical nature, including discussion of personal material relevant to my treatment
My health record, in part or in whole, or summaries of material from my health record
Other information
If other, please describe below:
500 words max
0/500
Confirmation
*
I understand that the information to be released may include the following: diagnoses and/or treatment for alcohol, drug or substance abuse; psychological or psychiatric conditions; AIDS/AIDS Related Complex (ARC) diagnoses and treatment; HIV test results; or sickle cell anemia. I have been informed of the risks, including but not limited to my confidentiality in treatment, of transmitting my protected health information by unsecured means. I understand that Vitalitas Denver, P.C. may not condition treatment, payment, or eligibility for benefits on my signing this authorization. I also understand that I may terminate this consent by providing written notice at any time, but that this authorization will terminate no later than when my treatment relationship with Vitalitas Denver, P.C. has ended.
Email
*
Phone Number (Home or Mobile)
Signature
*
Submit
Should be Empty: