Release of Information - Staff Requested
1320 South Frontage Road, Suite 200 Hastings, MN 55033-2481 651-500-0905 651-437-2616 fax LutzTherapy.com
Authorization for Electronic Communication
Client Name: Client Date of Birth: Name & Relationship of Individual Signing this Form: ,
Our electronic intake and consent forms utilize email communication for transmission of your information.
Email and text messaging, while efficient, are relatively insecure.
Please be informed that these methods, in the typical form, are not confidential means of communication. While we use encryption to secure the contents of emails sent between our webservers and your inbox, there is still a chance these communications, which may contain confidential information, could be intercepted.
The kind the parties that may intercept these messages include, but are not limited to:
We offer electronic documentation for convenience and to remove barriers to care. It is not a requirement to receive services. If you’d prefer not to utilize electronic documentation, please do not complete this form, and call us at 651-500-0905 to discuss alternative methods for completing this paperwork.
By proceeding past this page, and clicking the box below, you are acknowledging the risks explained above and agreeing to utilize our electronic forms and email communication.
I acknowledge understanding of the risks and consent to electronic communication.
Authorization for Release of Protected Health Information
The undersigned hereby authorizes Lutz Therapy/Tom Lutz & Associates to
The following information:
Allowable formats for the communication of this information include:
This information is to be released for the purpose of: This authorization can be revoked at any time but not retroactively to information exchanged. The individuals and organizations named above are released from legal responsibility or liability for release of the above information to the extent indicated authorized therein.
I understand that I may cancel this release at any time by notifying the provider in writing. I understand that the release will take effect on the date signed and will remain in effect for one year unless an earlier expiration date is indicated here:
Leave this empty:
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Release of Information - Staff Requested
Agree & Sign