communication waiver

Is the patient under the age of 18?

Yes No

At BMC-Troy, confidentiality is of the utmost importance.

You have requested communication with one of the staff members at the Behavioral Medical Center via e-mail or texting, which is not a standard procedure at our office.

As such, we require a signature from you to acknowledge that you understand the risks of e-mail communication and texting in general, as it relates to potential breaches in confidentiality.

An email or a text message, for example, may reach unintended recipients in error.

By signing this document, you understand and agree to the potential risks of e-mail or text communication and you understand that should information reach unintended recipients in error, our office will not be held liable.

Patient first name

Patient last name

Birthdate

Name of Parent/Guardian if patient is a minor

PatientParent/Guardian Signature

Reset Signature

Date: