2600 Michelson Dr, Irvine, CA 92612 Blairwellnessgroup.com Phone: 310-999-4996
BLAIR WELLNESS GROUP, A PROFESSIONAL PSYCHOLOGICAL CORPORATION
Dr. Cassidy Blair, Psy.D.
Consent for Email and/or Text Message Communication
Email and text messaging allows health care providers to exchange information efficiently for the benefit
of our patients. At the same time, we recognize that email and text messaging are not a completely
secure means of communication because these messages can be addressed to the wrong person or
accessed improperly while in storage or during transmission.
HIPAA requires that providers take reasonable steps to protect against these risks but acknowledges that
a balance must be struck between the need to secure protected health information (PHI) and the need to
ensure that clinicians can efficiently exchange important patient care information. My practice has
implemented such measures through obtaining informed consent from patients using any potentially
unencrypted electronic format.
Please practice discretion and best judgment when using email or text messaging. Most common and
appropriate uses of these forms of communication include:
1) Scheduling or rescheduling of appointments
2) Prescription related issues
3) Brief clinical questions
4) Billing related communication - including the sending of invoices and Superbills
Email or text messaging should not be used for:
1) Emergency situations. Under these circumstances, call 911
2) Disclosure of sensitive information that should otherwise be discussed during regular
appointments
If you would like to use email and/or text messages that may contain your protected health information,
please complete and sign this Consent below. You are not required to authorize the use of email and/or
text messaging and a decision not to sign this authorization will not affect your health care in any way. If
you prefer not to authorize the use of email and/or text messaging, I will continue to use U.S. Mail or
telephone to communicate with you.
______________________________________________ ______________________________
Patient’s Signature Date
______________________________________________
Name (please print)
______________________________________________________________________________
Personal email address where Blair Wellness Group, A Professional Psychological Corporation may send
you your health information (please print)
______________________________________________________________________________
Telephone number where Blair Wellness Group, A Professional Psychological Corporation may text you
your health information (please print)
2600 Michelson Dr, Irvine, CA 92612 Blairwellnessgroup.com Phone: 310-999-4996
BLAIR WELLNESS GROUP, A PROFESSIONAL PSYCHOLOGICAL CORPORATION
Dr. Cassidy Blair, Psy.D.
TELEHEALTH CONSENT FORM
I, _______________________(Patient) hereby consent to engage in Telehealth with Blair Wellness
Group, A Professional Psychological Corporation, PSY22022.
I understand that Telehealth is a mode of delivering health care services, including psychotherapy, via
communication technologies (e.g., Internet or phone) to facilitate diagnosis, consultation, treatment,
education, care management, and self-management of a patient’s health care.
By signing this form, I understand and agree to the following:
1. I have a right to confidentiality with regard to my treatment and related communications via Telehealth
under the same laws that protect the confidentiality of my treatment information during in-person
psychotherapy. The same mandatory and permissive exceptions to confidentiality outlined in the
[Informed Consent Form or Statement of Disclosures] I received from my therapist also apply to my
Telehealth services.
2. I understand that there are risks associated with participating in Telehealth including, but not limited to,
the possibility, despite reasonable efforts and safeguards on the part of my therapist, that my
psychotherapy sessions and transmission of my treatment information could be disrupted or distorted by
technical failures and/or interrupted or accessed by unauthorized persons, and that the electronic storage
of my treatment information could be accessed by unauthorized persons.
3. I understand that miscommunication between myself and my therapist may occur via Telehealth.
4. I understand that there is a risk of being overheard by persons near me and that I am responsible for
using a location that is private and free from distractions or intrusions.
5. I understand that at the beginning of each Telehealth session my therapist is required to verify my full
name and current location.
6. I understand that in some instances Telehealth may not be as effective or provide the same results as
in-person therapy. I understand that if my therapist believes I would be better served by in-person
therapy, my therapist will discuss this with me and refer me to in-person services as needed. If such
services are not possible because of distance or hardship, I will be referred to other therapists who can
provide such services.
7. I understand that while Telehealth has been found to be effective in treating a wide range of mental
and emotional issues, there is no guarantee that Telehealth is effective for all individuals. Therefore, I
understand that while I may benefit from Telehealth, results cannot be guaranteed or assured.
8. I understand that some Telehealth platforms allow for video or audio recordings and that neither I nor
my therapist may record the sessions without the other party’s written permission.
9. I have discussed the fees charged for Telehealth with my therapist and agree to them, and I have been
provided with this information in the [Informed Consent Form, Name of Payment Agreement Form, or
Credit Card Processing Agreement].
2600 Michelson Dr, Irvine, CA 92612 Blairwellnessgroup.com Phone: 310-999-4996
10. I understand that my therapist will make reasonable efforts to ascertain and provide me with
emergency resources in my geographic area. I further understand that my therapist may not be able to
assist me in an emergency situation. If I require emergency care, I understand that I may call 911 or
proceed to the nearest hospital emergency room for immediate assistance.
I have read and understand the information provided above, have discussed it with my therapist, and
understand that I have the right to have all my questions regarding this information answered to my
satisfaction.
[For conjoint or family therapy, patients may sign individual consent forms or sign the same form.]
______________________________________________ ______________________________
Patient’s Signature Date
______________________________________________
Patient’s Printed Name
Verbal Consent Obtained Therapist reviewed Telehealth Consent Form with Patient, Patient understands
and agrees to the above advisements, and Patient has verbally consented to receiving psychotherapy
services from Therapist via Telehealth.
______________________________________________ _____________________________
Therapist’s Signature Date
2600 Michelson Dr, Irvine, CA 92612 Blairwellnessgroup.com Phone: 310-999-4996
BLAIR WELLNESS GROUP, A PROFESSIONAL PSYCHOLOGICAL CORPORATION
Dr. Cassidy Blair, Psy.D.
Credit Card Processing Agreement
Name: ______________________________________________________________________
Payor’s Name (if different than the above):__________________________________________
______________________________________________________________________________
Credit Card Number
______________________________________________________________________________
Security Code (3 digits for Visa, MC, Discover; 4 digits for Amex) / Expiration Date / Billing Zip Code
______________________________________________________________________________
Email address or text message phone number for transaction receipts
I hereby authorize Blair Wellness Group, A Professional Psychological Corporation. to use the above
credit card, including circumstances where the credit card is not present. This credit card can be used to
pay for services rendered and for any outstanding balances on this client/patient’s account. Charges will
be made for services as described in the “Fee Schedule,” including fees for scheduled appointments,
charges for missed appointments or late cancellations, and for fees associated with services provided
outside of scheduled appointment times. This authorization is good through the credit card expiration
date.
If charges are disputed and reported to your credit card company, I agree to allow Blair Wellness Group,
A Professional Psychological Corporation. to contact my credit card company and disclose the purposes
of the disputed charges, which may include information regarding attendance or cancellations of
appointments.
______________________________________________ _____________________________
Authorized Signature Date
