Patient Permission Form

Parent, Teacher, and Treatment Professional Email Communication

The Selective Mutism Anxiety and Related Disorders Treatment Center (SMart Center) uses email correspondence as a method of communication with parents, teachers, and treatment professionals involved in the direct treatment of a specific named child in the event that telephone communication is not suitable due to time differences, difficult schedules, etc. When appropriate, our office staff uses email to schedule and confirm appointments, provide billing related documents, and answer questions regarding treatment and office policy.

Email is not an appropriate communication tool when a parent requires an immediate response or when the requested response is highly sensitive and/or complex in nature. Sensitive electronic information such as S-CAT® Program Comprehensive Treatment Plans are sent to families through a secure file-sharing service.

While the SMart Center understands the need for email correspondence under the appropriate circumstances, the SMart Center cautions that due to the nature of the technology involved and the public character of the SMart Center’s business, email may be less private than users may anticipate or desire. Consequently, the SMart Center cannot guarantee the confidentiality of email communication.

Should a parent, teacher, or treatment professional wish to engage in email communication with our office or professional staff, the SMart Center requires that the parent of a child/teen being treated at the SMart Center review the waiver set forth below and respond as the family feels is appropriate. Our office and professional staff will be authorized to respond to email requests from the identified email address(es) and names of individuals/institutions documented only if the parent(s) approve of this mode of communication.

Consent to the Release of Personally Identifiable Patient Information via Email

Recognizing that transmission via email may not be absolutely secure, I hereby consent to the SMart Center’s release of patient records/information via email in response to any request received from myself and/or the persons, institutions, and/or email address(es) set forth below. While the SMart Center will take precautions to avoid accidental releases of personally identifiable patient data by sending sensitive documents through a secure file sharing system, I recognize that the SMart Center cannot assure confidentiality in all transmissions via email. It is my intent that this Consent Form shall remain in effect, unless specifically withdrawn or modified in writing, during our child’s length of treatment at the SMart Center. I further understand it is my responsibility to notify the SMart Center if my email address changes.

I understand that if I initiate email correspondence with the SMart Center, there is no way to guarantee the information I include in my email can remain absolutely secure. By initiating email correspondence with the SMart Center, I understand that I am accepting the potential risk involved with email communication. *

By checking this box, I agree to the terms of this agreement form.

By checking this box, I do not agree with the terms of this agreement. I will allow paperwork to be sent through a secure file-sharing system, but do not consent to direct email correspondence.

Below are the names and contact information of the individuals (in addition to myself) that I allow the SMart Center to correspond with via email:

	Name	Relationship to Child	Email Address
1.	Name	Relationship to Child	Email Address
2.	Name	Relationship to Child	Email Address
3.	Name	Relationship to Child	Email Address
4.	Name	Relationship to Child	Email Address
5.	Name	Relationship to Child	Email Address