Non-Secure Communication Consent

CONSENT FOR NON-SECURE COMMUNICATION OF PROTECTED HEALTH INFORMATION (PHI)

Please complete this contract and submit.

I understand that Alabama Lifestyle Medicine (ALLM) has a secure (encrypted) email. Despite that, I request that the ALLM use non-secure (unencrypted) email, text, and/or video messaging to communicate with me on the following: Communications regarding my appointments: To send me copies of any records I have requested. For any communication about my health, treatments, and health care in general. I request that the ALLM use the following option(s) for non-secure communication with me by use of the following: Personal email, Text (SMS) messaging, Video messaging (such as Zoom or Skype), Client verbally consents during this time of emergency

Name(Required)

I understand that non-secure email may be intercepted by persons other than the sender and recipient. I accept all liability for any/all consequences of using this non-secure communication option. I release ALLM from any/all liability from using non-secure communication at my direction. I understand that I am not required to sign this agreement in order to receive care from ALLM. I understand that I may terminate this consent at any time. This consent will remain in effect until I notify ALLM in writing or by email that I revoke my permission for this document

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Time(Required)
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By:

Name(Required)

Relationship to Patient (if other than patient)