Email Authorization

Center for Family Development

1258 High Street, Eugene, OR 97401 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:

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:

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Signature Certificate
Document name: Email Authorization
lock iconUnique Document ID: 048fc1662d9473645930604b10be4b332d9e9889
Timestamp Audit
August 28, 2020 11:03 am PSTEmail Authorization Uploaded by Jason Dooley - IP
August 31, 2020 12:19 pm PSTCFD Main - added by Jason Dooley - as a CC'd Recipient Ip: