Contact & Communication Consent Form

COVID-19 UPDATE

The current global health crisis has changed how we live and work. All medical providers are needed at this time. In order to keep staff healthy, we're offering telehealth visits using a HIPAA-compliant platform, Zoom Medical.

LET'S GET STARTED!

1. What's your appointment preference?

When would you like to schedule your appointment?

I prefer mornings.

I prefer afternoons.

I prefer the lunch hour.

Did someone refer you, or are you making the request yourself?

Anything else you'd like us to know about your schedule?

First Name

Middle Initial

Last Name

Gender

Date of Birth

Month

Day

Year

*Complete Street Address

City

State

Zip

Email (double check, please)

Cell Phone

May we email/text, and call you at this number?

Yes

We use HIPAA-compliant technology to reduce wait times, improve the intake process, and ensure that you have access to your provider when needed. We need your consent in order to move forward. Your provider will explain each service in detail. Please call or email if you have questions now - or prefer a non-digital intake process.

Communication Consent Required:

I consent to receive text and email notifications for my appointments, invoices, and receipts.

I consent to HIPAA-compliant texting, when necessary, or to enhance my care.

I consent to providing and allowing charges on my credit card for the balance due at the time of the appointment (self-pay clients only). If using insurance, I consent to charges for my co-payment, and co-insurance once my claim has been processed.

Lastly, by sending this, I consent to the use of digital forms and the above terms.

Next Step? Complete the INTAKE FORM for your provider. Please select a numerical code and use the code to complete the intake form. All forms are HIPAA-compliant and encrypted.

My Personal Number:

Number (Minimum of 3 digits)

Your message will be encrypted and can only be read by Kama Jensen.

Kama Jensen

Intake Team, Conscious Living Counseling & Education Center

HI! My name is Kama. I'll make sure your intake process goes well. You'll start with this form. Then, based on your comfort level, we can complete the entire intake process using HIPAA-compliant digital forms, or I can call you to complete the intake process. You have options. Select the right one for you. ________________________________ Privacy is everything to us. Hushmail is a recognized company and is HIPAA compliant. This means it offers the highest level of security for online communication and monitors security closely.

701-478-7199