Authorization for Electronic Communication
Name: Date of Birth:
Electronic communication means using Web sites, mobile phones, email, text messaging, online social networking, video, or other electronic methods and technology to send and receive messages, or to post information so that it can be retrieved by others or used later.
CFD offers the opportunity to communicate by electronic means using email and text messaging.
Risks of Using Electronic Communication
Electronic communications have possible risks that should be considered before using to communicate. If I am worried about any information being seen by other people, or if my question or issue is urgent, I will call CFD staff instead of communicating by electronic means.
I understand the following risks apply when communicating by electronic means including, but not limited to, the following:
Use of Electronic Communication
CFD uses reasonable means to protect the security and confidentiality of email and text message information sent and received. However, because of the risks outlined above, CFD cannot guarantee the security and confidentiality (privacy) of electronic communications and will not be liable for my improper use and/or disclosure of confidential information (including Protected Health Information that is the subject of the federal Health Insurance Portability and Accountability Act of 1996).
I agree to and request the following regarding the use of electronic communication with CFD:
I authorize electronic communications by:
My signature affirms that I have read and understand this form and have had the opportunity to ask questions.
This document is being signed by: ClientPersonal Representative, see below
If you are signing as the Personal Representative, please complete the following section; otherwise, proceed to signing the form.
Full legal name of Personal Representative:
Relationship to client:
Definition of Personal Representative:For Adults: A person with legal authority to make healthcare decisions on behalf of the adult. Supporting documentation required.For Youth: A parent, guardian, or other person acting in the place of a parent with legal authority to make healthcare decisions on behalf of the minor child. Supporting documentation may be required.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Authorization for Electronic Communication
Agree & Sign