Electronic Communication Consent Electronic Communications Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY Date of Request* Date Format: MM slash DD slash YYYY Method of Communication Preference*I request that the following communications from Yolo Hospice / Citizens Who Care / YoloCares be delivered to me by provided electronic means. I understand that this form of communication may not be secure, creating a risk of improper disclosure to unauthorized individuals. I am willing to accept that risk, and I will not hold the organization responsible should such an incident occur. Email Text Teleconference (Zoom, etc.) Acknowledgement and Agreements*I understand and agree that the requested communication is not secure, making my Protected Health Information (PHI) at risk for receipt by unauthorized individuals. I accept that risk and will not retaliate against the organization in any way should that occur. I understand and agreeNameThis field is for validation purposes and should be left unchanged. Share this:TweetLike this:Like Loading...