Cordelia Kraus, MA, LPC, CADC I
ph: 503.662.2944 ・ email: firstname.lastname@example.org ・ web: cordeliakraus.com
office address: 2505 SE 11th Ave, Suite #232, Ford Building, Portland, OR 97202
vital space, llc
CONSENT FOR TRANSMISSION OF PROTECTED HEALTH INFORMATION BY NON-SECURE MEANS
I authorize Cordelia Kraus (vital space, llc) to transmit the following protected health information related to my health records and health care treatment:
Information related to the scheduling of meetings or other appointments
Information related to billing and payment
Completed forms, including forms that may contain sensitive and/or confidential information
Information of a therapeutic or clinical nature, including discussion of personal material relevant to my treatment
Invitation to join the secure client portal
By the following non-secure means:
SMS text message (i.e. traditional text messaging) or other type of “text message.”
I have been informed of the risks, including but not limited to my confidentiality in treatment, of transmitting my protected health information by unsecured means. I understand that I am not required to sign this agreement in order to receive treatment. I also understand that I may terminate this authorization at any time.
I understand that Cordelia Kraus (vital space, llc) makes available the following means of communication that are designed to be secure, and I still choose to authorize the above-selected non-secure means:
Secure client portal for setting appointments, billing, completion of forms
Disclosure Regarding Third-Party Access to Communications
Please know that if we use electronic communications methods, such as email, texting, and possibly others, there are various technicians and administrators who maintain these services and may have access to the content of those communications. In some cases, these accesses are more likely than in others.
Of special consideration are work email addresses. If you use your work email to communicate with me, your employer may access our email communications. There may be similar issues involved in school email or other email accounts associated with organizations that you are affiliated with. Additionally, people with access to your computer, mobile phone, and/or other devices may also have access to your voicemail, email and/or text messages. Please take a moment to contemplate the risks involved if any of these persons were to access the messages we exchange with each other.
By signing this document I am agreeing that I have read and understood the options and considerations and consent to the transmission of the above-selected information by the above-selected means.