Authorization for Electronic Communication

1258 High Street, Eugene, OR 97401

Phone 541-342-8437 | Fax 541-242-2999

Name:     Date of Birth:

Authorization for Electronic Communication
Email and Text

Electronic Communication

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:

  • Electronic communication can be forwarded to other people, saved on electronic devices, or printed out on paper for storage.
  • Electronic communication can be sent to the wrong person by accident.
  • Email or text messages can be used as evidence in court.

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 will receive electronic communications from program staff at the contact information I provide.
  • Text messages may be used for scheduling purposes, appointment confirmation, resource information, and administrative purposes only.
  • Email and/or text message communication between me and CFD may be made part of my electronic health record. CFD staff who are authorized to view my electronic health record will also have access to these communications.
  • CFD may forward electronic communications to other CFD staff as necessary for diagnosis, treatment, reimbursement, and other operations. CFD will not, however, forward email or text messages to parties outside of CFD who are not involved in my care, without my prior written consent, except as authorized or required by law.
  • If I send an email or text message that requests a response from a specific staff person and I have not received a response within two (2) business days, it is my responsibility to call CFD to discuss the issue by phone.
  • I understand that clinical services cannot be provided over email or text messaging, and I will not use electronic communication as a form of therapy.
  • I will not forward links, forwards, or spam texts or emails to CFD, which may introduce viruses into electronic systems.
  • Emails from CFD will be encrypted (secure) and will require that I establish a password to view the information. I can request that emails be sent unencrypted (unsecure), and my acknowledgement of the risks will be documented.
  • I am responsible for my own actions related to the use of my devices, including paying for any charges incurred by my wireless plan, safeguarding passwords, and keeping electronic communication confidential.
  • I will immediately inform CFD of changes in my email address or text messaging number. Failure to do so may result in information being sent to the previously used number or address.

I authorize electronic communications by:


I would like to receive appointment confirmations by (choose one):

My signature affirms that I have read and understand this form and have had the opportunity to ask questions. I may withdraw authorization for electronic communication by informing CFD in writing.

This document is being signed by:

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:

Signature arrow sign here

Signature Certificate
Document name: Authorization for Electronic Communication
lock iconUnique Document ID: 31438db29428b7409eca1e5099a6b65bcd513b0b
Timestamp Audit
November 10, 2023 10:39 am PDTAuthorization for Electronic Communication Uploaded by Do Not Reply - IP
November 10, 2023 10:49 am PDTCFD Main - added by Do Not Reply - as a CC'd Recipient Ip:
March 11, 2024 1:32 pm PDTCFD Main - added by Do Not Reply - as a CC'd Recipient Ip:
April 23, 2024 11:05 am PDTCFD Main - added by Do Not Reply - as a CC'd Recipient Ip:
April 23, 2024 11:06 am PDTCFD Main - added by Do Not Reply - as a CC'd Recipient Ip:
April 23, 2024 11:11 am PDTCFD Main - added by Do Not Reply - as a CC'd Recipient Ip: