Electronic Communication Authorization and Consent

Until I tell you in writing to stop, I authorize Smile Logic Orthodontics to transmit patient information relating to my appointments, treatment, health, or payment by email, text, or other electronic means, without encryption or special security precautions, to me or someone I designate, or to other health care providers, health plans and others involved in my treatment, payment for my treatment, or Smile Logic Orthodontic’s health care operations. The patient information that may be emailed may include my x-rays, health history, diagnosis, treatment, and payment records.

I understand that:

  • I do not have to sign this form.
  • My treatment, payment, enrollment and eligibility for benefits will not be affected by my decision about signing this form.
  • If I do not sign this form, Smile Logic Orthodontics may use other ways to send my information, such as U.S. Mail, or may ask me to send my information to third parties myself.
  • There is some risk that emails and other electronic messages may be improperly acquired by hackers or received by unintended recipients. If that happens, the information may be redisclosed and no longer protected by privacy law.
  • Smile Logic Orthodontics does not email or text such sensitive personal information as Social Security number, credit card number, mental health diagnosis, genetic information, alcohol/substance abuse, or positive HIV status unless the patient insists.

I can tell you in writing to stop emailing and/or texting my patient information at any time, but if I do so, this will not affect emails and texts that Smile Logic Orthodontics already sent before receiving my written instructions to stop.