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Seasons

Electronic Communication Agreement

Electronic communications, including but not limited to, emails and text messages (hereinafter “Electronic Communications”), provide an opportunity to communicate with the healthcare providers at Seasons Center for Behavioral Health (“Seasons Center”).

The following is intended as an agreement between Seasons Center and

General Considerations

As your healthcare provider, Seasons Center will treat Electronic Communications with the same degree of privacy and confidentiality as written medical records. Seasons Center has taken reasonable steps with internal information technology systems and program policies to protect the security and privacy of your personal identifying and health information in accordance with the security guidelines required by the Health Information Protection and Accountability Act of 1996, as amended (“HIPAA”).
Communicating electronically with Seasons Center has benefits, including but not limited to more prompt access to your healthcare provider and reminders of upcoming appointments. However, communicating electronically also has its risks, including but not limited to the below:

Standard email services, including, but not limited to, Yahoo, Hotmail, and Gmail, are not secure. This means that the email, including any individually identifiable health information and other sensitive or confidential information that may be contained in such email are not encrypted and could be misdirected, disclosed to, read or intercepted by, unauthorized third parties.
Text messaging services are not secure. This means that the text message, including any individually identifiable health information and other sensitive or confidential information that may be contained in a text message are not encrypted and could be misdirected, disclosed to, read or intercepted by, unauthorized third parties.
Seasons provides telehealth services using a secure communication system. However, it is important to be aware of the environment that you are in when you receive telehealth services in order to protect your own confidentiality, such as if others can see or overhear your interaction with your provider.

I have read and understood the above description of the risks and responsibilities associated with Electronic Communications with Seasons Center. I acknowledge that commonly used Electronic Communications are not secure.

Please check one of the three below statements:

Having been informed of the risks associated with Electronic Communications, I consent to, accept the risk in and still desire to communicate with Seasons Center via Electronic Communications. I understand that I can withdraw this consent authorizing Seasons Center to communicate with me via Electronic Communications at any time by written notification to Seasons Center. I agree to notify Seasons Center and complete a new Electronic Communications Agreement when my cell phone number or email address changes.

Email Address

Cell Phone

Having been informed of the risks associated with Electronic Communications, I consent to, accept the risk in and still desire to communicate with Seasons Center via Electronic Communications only with respect to appointment reminders. I understand that I can withdraw this consent authorizing Seasons Center to communicate with me via Electronic Communications at any time by written notification to Seasons Center. I agree to notify Seasons Center and complete a new Electronic Communications Agreement when my cell phone number or email address changes.

Email Address

Cell Phone

Having been informed of the risks associated with Electronic Communications, I do not consent to, accept the risk in and desire to communicate with Seasons Center via Electronic Communications. I understand that I can change my mind and provide a consent authorizing Seasons Center to communicate with me via Electronic Communications at a later time by written notification to Seasons Center.

To the extent that I have checked Box A or B, I release and hold harmless Seasons Center, its provider(s) and their staff, employees, affiliates, agents, officers, and principals from any and all expenses, claims, actions, liabilities, attorney fees, damages, losses of any kind that I may have resulting from Electronic Communications between Seasons Center and me and/or the minor identified based on this authorization given to Seasons Center to communicate with me via Electronic Communications.

By entering your name and email address on this document, you agree that you are electronically signing the Electronic Communication Agreement. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement.

Digital Signature

Date

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Mission

Guiding individuals and families towards a meaningful and fulfilling life.

Vision

Best in the Midwest in Behavioral Health

Values

Innovation, Impact, Influence

Seasons

Electronic Communication Agreement