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Email Authorization

1258 High Street, Eugene, OR 97401

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

Email Authorization

Name: Date of Birth:

There may be times during therapy when my therapist wants to provide me with written information, such as a copy of my Service Plan. If the best way to get information to me is by email, I understand I have a choice to have emails sent securely to protect the information or sent unsecure to make it easier for me to access the information.

Please select one of the options below:

I do not have email and/or I want written information sent to me in the mail by the postal service.

Any information sent by secure email is encrypted to protect the information in transit. I understand and accept that to access the encrypted email, I will be prompted to create a username and password. I request that information be sent by encrypted email.

Any information sent by unsecure email is not encrypted and has the potential of being intercepted. I understand and accept the potential risks of email communication and request information be sent by unsecure email.

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.

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Email Authorization

1258 High Street, Eugene, OR 97401

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

Email Authorization

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