Request for Non-Secure Communications

By signing or e-signing this document, I am acknowledging that I have read and agree with the statements below:

(Name)

AUTHORIZE: Tristan Robinson, Ph.D., 30 Ardmore Ave., Suite 45, Ardmore, PA 19003-9998, NPI # 1265783831

TO TRANSMIT TO ME BY THE NON-SECURE COMMUNICATION METHOD(S) CHECKED BELOW THE FOLLOWING TYPE(S) OF PROTECTED HEALTH INFORMATION RELATED TO MY HEALTH RECORDS AND HEALTH CARE TREATMENT:

Information related to the scheduling of appointments and/or reminders to complete documents or questionnaires

Information related to billing and payment (but not to include any financial or claims-related identifiers such as credit card numbers, insurance plan numbers, diagnosis codes, or procedure codes.)

Other (specify):

I am aware that this information may reveal my participation in past, present, or future behavioral health care services with Tristan Robinson

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 am aware that the following means of communication, designed to be secure and to maintain confidentiality, are available for me to use to communicate with Tristan Robinson:

Method 1: Secure message via my client portal: https://tristan-robinson.clientsecure.me.
Method 2: Encrypted email (trobinson@tristanrobinsonphd.com).
Method 3: Iplum smartphone app to receive and send encrypted text messages.

I have been informed of the risks to privacy and confidentiality of transmitting my protected health information through unencrypted email or text messages. I understand that there are inherent risks involved with sending and receiving information related to my health care over the internet (including through any form of email, text, or secure messaging), but that these risks can be greatly reduced by using encrypted communication methods. I have considered the potential negative consequences of any unauthorized access to, use, or disclosure of information shared electronically between myself and my therapist, and I am choosing to accept those risks.

I AM REQUESTING THE USE OF THE FOLLOWING NON-SECURE COMMUNICATION METHODS TO TRANSMIT THE ABOVE-NAMED TYPE OF PROTECTED HEALTH INFORMATION:

Unencrypted email

Unencrypted text message*

* Currently not available as an option

To comply with federal telecommunications law, I also need to ask you to read my Mobile Privacy Policy and obtain your opt-in consent to receive text messages. Click the links above to view these items.

Your information will be encrypted.