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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:
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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
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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.
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