YOUR AUTHORIZATION OF THE TRANSMISSION OF YOUR PROTECTED HEALTH INFORMATION BY NON-SECURE MEANS
By signing electronically below, I:
- Authorize NYC CBTp therapists and/or office staff to transmit to me by non-secure media (e.g. email and SMS/text message) Protected Health Information (PHI) related to the a) scheduling of therapy sessions and/or other appointments and b) billing and payment for therapy sessions or other services;
- Agree that this authorization will terminate only if/when I notify NYC CBTp in writing that this agreement should be terminated;
- Agree that I have been informed of the risks, including, but not limited to, the confidentiality of my treatment when transmitting my PHI by non-secure means;
- Understand that I am not required to sign this agreement in order to receive treatment; and
- Understand that I may terminate this authorization at any time by notifying NYC CBTp in writing.