Class Registration
Use this form to register for class. You will recieve an email with instructions for submitting payment.

AUTHORIZATION TO ELECTRONICALLY COMMUNICATE PROTECTED HEALTH INFORMATION
You are authorizing Emerge (and all therapists who work at Emerge) to send you future correspondence regarding your treatment via email or text. Your authorization does not obligate this therapist to communicate by email/text or cease non- electronic communication.

I understand and agree with all of these statements.

  • I understand that any email/text transmission between my provider and me/the patient will become part of my medical record. These email/text transmissions may be disclosed in accordance with future authorizations.
  • I understand that I have the right to revoke this authorization at any time by indicating so above. If I want to revoke this authorization, I must do so in writing and address it to the entity that I had previously authorized to disclose my information. I understand that if I revoke this authorization, it will not apply to any information already released as a result of this authorization.
  • I understand that this authorization is voluntary and that I may refuse to sign it. I also understand that the institutions or individuals named above cannot deny or refuse to provide treatment if I refuse to sign this authorization.
  • I understand that, once information is disclosed pursuant to this authorization, it is possible that it could be disclosed by the entity that receives it for authorized purposes under the HIPAA privacy rule.
Alert for Electronic Communication

Clients and/or personal representatives who want to communicate with their health care providers by email/text should consider all of the following issues before signing an authorization to Electronically Communicate Protected Health Information:

  1. Email/text can be forwarded, intercepted, printed and stored by others.
  2. Email/text communication is a convenience and is not appropriate for emergencies or time- sensitive issues.
  3. Highly sensitive or personal information should only be communicated by email/text at the patient’s discretion (i.e., HIV status, mental illness, chemical dependency, and workers compensation claims).
  4. Employers generally have the right to access any email received or sent by a person at work.
  5. Staff other than the health care provider may read and process email/text.
  6. Clinically relevant messages and responses will be documented in the medical record at the provider’s discretion.
  7. Communication guidelines must be defined between the clinician and the patient, including (1) how often email/text will be checked, (2) instructions for when and how to escalate to phone calls and office visits and (3) types of transactions that are appropriate for email/text.
  8. Email message content must include (1) the subject of the message in the subject line (i.e., schedule change, appointment request, etc.) and (2) clear client identification such as client name in the body of the message.
  9. Emerge (and the therapists who work at Emerge) will not be liable for information lost or misdirected due to technical errors or failures.