Ravenswood Therapy Group

Consent For Electronic Transmittal

Dear Client:

I will offer electronic receipt of monthly invoices and statements of account. It is my hope that this will provide my clients with a more efficient and accurate method of keeping track of their services and balances. Forms will maintain the same format and will be sent once a month. Should you be interested in receiving your invoices and statements electronically please read and complete the information below.

will use reasonable means to maintain security and confidentiality of Electronic Communication information sent.


Transmitting information electronically has risks that you should consider. These include, but are not limited to, the following:
  • Electronic communications can be intercepted, altered, forwarded or used without authorization or detection.
  • Electronic communications can be circulated, forwarded and stored in paper and electronic files.
  • Electronic communication senders can type in the wrong E-mail address.
  • Electronic communications may be lost due to technical failure during composition, transmission and/or storage.


I have read and fully understand the information in this authorization form. I consent to the Electronic Communication Conditions and agree to abide by the guidelines listed above. I further understand that this Electronic Communications Relationship may be terminated if I repeatedly fail to adhere to these guidelines. I understand and accept the risks associated with the use of unsecured Electronic Communications. I further understand that, as with all means of Electronic Communication, there may be instances beyond the control of the family and the health provider where information may be lost or inadvertently exposed, such as during technical failures, natural disasters, etc.
Client Name:(Required)
Parent/Legal Representative:(Required)
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.