Use this form to document your consent for our communication of your confidential information with other individuals or agencies.
Step 1 of 4
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 have read the Client Policy, HIPAA Information Form and Communications Policy. I understand my rights as a client of Tom Lutz and Associates and the limits of confidentiality. I also understand my financial responsibilities as a client.
I have been informed of the risks, including but not limited to my confidentiality in treatment, of transmitting my protected health information by unsecured means. My signature means that I have read and understand the above mentioned documents.
I hereby assign payment of insurance benefits to include major medical benefits to Tom Lutz and Associates and to release any medical information deemed necessary to secure payment. I understand that if I have insurance coverage, but do not give the necessary information needed for billing purposes, I will be responsible for 100% of the charges I incur.
