Authorization for Electronic Communication
As a convenience to me, I hereby request that Choice Network communicate with me via electronic communication such as internet, email or text message. I understand that this means Choice Network will transmit information to me via electronic communications that may contain personal or confidential information. I also understand Choice Network stores home study information on the Statewide Automated Child Welfare Information System as directed by the Ohio Department of Job and Family Services
I understand there are risks inherent in the electronic transmission of information by email, on the internet, via text message, or otherwise, and that such communications may be lost, delayed, intercepted, corrupted or otherwise altered, rendered incomplete or fail to be delivered. I further understand that any protected health information transmitted via electronic communications pursuant to this authorization may not be encrypted. As the electronic transmission of information cannot be guaranteed to be secure or error-free and its confidentiality may be vulnerable to access by unauthorized third parties, Choice Network shall not have any responsibility or liability with respect to any error, omission, claim or loss arising from or in connection with the electronic communication if information by Choice Network to me.
After being provided this notice of the security risks inherent in the use of electronic communications, I hereby expressly authorize Choice Network to communicate electronically with me, which may include the transmission of protected health information electronically. I understand that in the event I no longer wish to receive electronic communication from Choice Network, I may revoke this authorization by providing written notice to Choice Network at 693 1⁄2 High St. Ste. G., Worthington, OH 43085 or fax at 866-542-2234.
I agree that Choice Network may communicate with me electronically unless and until I revoke this authorization by submitting notice to Choice Network in writing. This authorization does not allow for electronic transmission of my protected health information to third parties and I understand I must execute a separate authorization for my protected health information to be disclosed to third parties.
I hereby authorize the transmission of my protected health information electronically as described above.