Confidential Handling of Health Information CONFIDENTIAL HANDLING OF HEALTH INFORMATION * All reasonable requests to communicate with you and to convey health information, as well as billing information, using your preferred methods, will be accommodated. Please list and check ALL methods by which you approve and prefer for receiving your health and/or billing information. I request that Monya Cohen, Psy.D., LLC handle confidential health information in the following way(s). Name of Patient: First Name Last Name Home Phone (###) ### #### Cellular Phone (###) ### #### Okay to Text? Yes No Work Phone (###) ### #### Email Address * Send to the Following Address: ELECTRONIC SIGNATURE AND CONSENT * I understand that there may be times when I may provide the therapist with additional means for communication, outside of those listed above. It will be understood that these too will be considered patient-authorized confidential communications. Below is my electronic signature. First Name Last Name If signed by a legal guardian, personal representative, or other, please state your relationship to the patient: Date Signed * MM DD YYYY Thank you! Your form has been submitted.
