If there are people in your life that you these communications, please talk with don’t want accessing about ways to keep your communications safe and confidential. Megan Smith-Sallans CONSENT FOR TRANSMISSION OF PROTECTED HEALTH INFORMATION BY NON-SECURE MEANS I consent to allow to use unsecured email and mobile phone text messaging to Megan Smith-Sallans transmit to me the following protected health information: Information related to the scheduling of meetings or other appointments Information related to billing and payment Any other questions that the client may ask or information client requests via email or mobile phone text messaging. 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 consent at any time. (Signature of client) Date Communications Policy Megan Smith Psychotherapy P.C. Communications Policy Contacting Me When you need to contact for any reason, these are the most effective ways to get Megan Smith-Sallans in touch in a reasonable amount of time: By phone (402-871-5920.) You may leave messages on the voicemail, which is confidential. By secure text message By secure email By the secure contact page on the website (www.megansmiththerapy.com). If you wish to communicate with me by normal email or normal text message, please read and complete the Consent For Non-Secure Communications form included with these office policies. I subscribe to the following service(s) that can allow us to communicate more privately through the use of encryption and other privacy technologies. None of them will cost you money, but each requires some setup before they can be used. Please ask if you would like to use any of these services: Encrypted email. Secure text messaging. This service can be used on a computer or smartphone. Secure online video chat software. If you need to send a file such as a PDF or other digital document, please send using the secure email service, please send via the secure contact form on the website, please print and FAX it to 402-915-5072.
If there are people in your life that you don’t want accessing these communications, please talk with Megan Smith-Sallans about ways to keep your communications safe and confidential. CONSENT FOR TRANSMISSION OF PROTECTED HEALTH INFORMATION BY NON-SECURE MEANS I consent to allow Megan Smith-Sallans to use unsecured email and mobile phone text messaging to transmit to me the following protected health information: Information related to the scheduling of meetings or other appointments Information related to billing and payment Any other questions that the client may ask or information client requests via email or mobile phone text messaging. 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 consent at any time. (Signature of client) Date Communications Policy Megan Smith Psychotherapy P.C. Communications Policy Contacting Me When you need to contact Megan Smith-Sallans for any reason, these are the most effective ways to get in touch in a reasonable amount of time: By phone (402-871-5920.) You may leave messages on the voicemail, which is confidential. By secure text message By secure email By the secure contact page on the website (www.megansmiththerapy.com). If you wish to communicate with me by normal email or normal text message, please read and complete the Consent For Non-Secure Communications form included with these office policies. I subscribe to the following service(s) that can allow us to communicate more privately through the use of encryption and other privacy technologies. None of them will cost you money, but each requires some setup before they can be used. Please ask if you would like to use any of these services: Encrypted email. Secure text messaging. This service can be used on a computer or smartphone. Secure online video chat software. If you need to send a file such as a PDF or other digital document, please send using the secure email service, please send via the secure contact form on the website, please print and FAX it to 402-915-5072.
HIPAA-20142.docx