COMMUNICATION CONSENT
Those interacting or referred to our office (directly or by a third party) hereby give consent to George Zaky, Psy.D., LMHC, LLC/EPA, and its staff to communicate with me via email, phone, text message, or any other means of electronic communication, for the purpose of scheduling appointments, requesting information, receiving information about the services provided, and answering any questions I may have.
I understand that communication through electronic means is not completely secure and may be subject to interception or unauthorized access. I acknowledge that George Zaky, Psy.D., LMHC, LLC/EPA, has taken reasonable measures to ensure that communications are protected and will not be disclosed to any unauthorized parties.
I understand that the Health Insurance Portability and Accountability Act of 1996 (HIPAA) sets forth certain privacy and security rules that govern the use and disclosure of my protected health information (PHI). I acknowledge that George Zaky, Psy.D., LMHC, LLC/EPA is committed to complying with all applicable HIPAA regulations.
I also give consent for George Zaky, Psy.D., LMHC, LLC/EPA and its staff to communicate with potential clients who have expressed an interest in receiving services from George Zaky, Psy.D., LMHC, LLC/EPA, as well as those referred by any agency or third party, using the same methods of electronic communication.
I understand that I may withdraw my consent at any time by notifying George Zaky, Psy.D., LMHC, LLC/EPA, in writing. In the event that I withdraw my consent, I acknowledge that George Zaky, Psy.D., LMHC, LLC/EPA, may be unable to provide me with certain services or options.