I hereby authorize the office of Dr. Ellen Dye, Ph.D. to transmit protected health information to me via electronic communication.
Electronic communication (e-mail, text messaging, etc.) is a non-secure means of communication, and I understand that there is a remote possibility that such communication could be intercepted by another person. By signing this authorization, I accept those risks and release Ellen Dye, Ph.D. From any legal responsibility or liability in the event that my protected health information is illegally intercepted by another person.
I understand that I may revoke this authorization in writing at any time except to the extent that communications have been made prior to my revocation in reliance on this authorization and that such communications shall not constitute a breach of my right to confidentiality.
To ensure maximum confidentiality, it is best to keep electronic communications brief and to primarily address practical matters such as scheduling. Electronic communications should not be used as a means of seeking clinical feedback or in case of emergency. Client information included in electronic communications should ideally be restricted to information you would be comfortable having as public knowledge.