Electronic Communication Consent

Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Date of Request*
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 agree
Phone
This field is for validation purposes and should be left unchanged.