1250 SE Maynard Road, Ste. 204
Cary, NC 27511


Ph: 919-371-4378
Fax 919-300-7943

www.slteletherapy.com

 
Alternative Communications Request Form

Alternative Communication Request Procedure:
  1. The client will be provided with information about the risks to their confidentiality that will arise in the use of the alternative communication method they wish for the practice to use.  The information will be provided in a manner that the client can understand, although it is not necessary to provide detailed information about the nature of encryption or information security.
  2. The client will indicate, in writing, the following items:
    1. The alternative communication method through which they desire to receive their Protected Health Information (PHI) from the practice, along with the associated contact information at which they desire to receive it.
    2. The nature and extent of the PHI they wish to allow to be transmitted through this method.
    3. That they have been informed of the risks in requesting alternative communication of their PHI and that they still wish to receive it.

SOME RISKS OF EMAIL COMMUNICATION AND TEXTING:
  • Email and texts are not secure unless they are encrypted.  Most emails and email service providers as well as wireless providers do not provide encrypted email or texting.  Silver Linings email and text communication with you will not be encrypted.
  • An email service or wireless provider may retain or inspect copies of emails.
  • Copies of emails or texts may exist even after you delete them.
  • It is easy for third parties to send fake emails and texts.

YOUR RESPONSIBILITIES:
  • If you communicate back to a Silver Linings employee or therapist via email or text, and do not hear back, it is your responsibility to follow up.
  • You understand that email and texting is not a substitute for office visits or phone calls.
  • You understand that NO EMERGENCY SITUATION should be communicated via email or text.

Please indicate the methods of alternative communication with Silver Linings that are acceptable to you by placing a check:
                  
           
 
 
 
If Email is acceptable, please indicate the email you want to use to receive your information:
If Texting is acceptable, please indicate the cell phone number you want to use to receive your information:
I understand that one of my rights is to be able to choose how I am contacted.
Client Statement: Please check:
I give permission for Silver Linings to contact me at work.
Yes    No
I give permission for Silver Linings to leave voice messages for me at:
I give permission for Silver Linings to leave voice messages for me at:
I give permission for Silver Linings to leave text messages for me at:
Home
Work
Work
Please be aware that text messages and voice mail may not be secure and are not HIPAA compliant; however, our payment portal on the website is encrypted and uses SSL certification for secure connections and payments.
I, , have been informed of the risks in requesting alternative communications of my Protected Health Information (PHI) and I still wish to receive it in the methods indicated above.

Signature Instructions:
Touch Screen: use finger or stylus to sign
Desktop Monitor: use mouse or touchpad to sign

 
Client Signature:
Guardian/Power of Attorney Signature:

Therapist Name and Signature:

Date: