I, (Name of Client), authorize Karla Garcia-Khan, PLLC (Karla Garcia, LW60672340)

To transmit protected health information related to my health records and health care treatment as indicated by a check mark on the following lines:

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• Appointment Reminders

• Information related to the scheduling of meetings or other appointments.

• Information related to billing and payment (including receipts I request using the application at time of payment)

• Billing that includes required diagnostic information for insurance reimbursement.

• Records requested on my behalf using a HIPPA Release Form

Via the non-secure media identified bellow:

• Text Messages / SMS (Short message services) to your phone

• Voice/Phone Call

• Fax Transmission

• Standard unencrypted email

• Postal Mail or Non-USPS shipping

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. I understand that I am not required to sign this agreement in order to receive treatment. I also understand that I may terminated this authorization at any time.

I understand that Indigo Your Practice Name PLLC makes available to me the following means of communication are designed to be secure, and I still choose to authorize to the above-named non-secure means: 

• Encrypted Email using Microsoft Office Encryption that requires me to create and use a anonymous user ID and Password

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