Client/Parent/Legal Guardian Acknowledgment and Consent

Electronic Communication Policy

By signing this form, I acknowledge and consent to the following conditions regarding communication with DMV Medical Group, LLC:

1. Email, Phone, and Text Communication

A. Response Time: DMV Medical Group cannot guarantee that any email, voicemail, or text message will be read or responded to within a specific period. Messages will be answered Monday–Friday during operating hours unless otherwise specified by DMV Medical Group. Messages will not be answered outside of these hours, on weekends, or holidays.

B. Emergency Situations: Email, voicemail, and text messaging are not appropriate for urgent or emergency situations. If you are experiencing a mental health emergency, call 911 or 988, or go to the nearest emergency room.

C. Message Content: Emails and text messages should be concise. For complex or sensitive matters, clients/parents/legal guardians should call the office or schedule an appointment.

D. Medical Records: Email communications may be printed and filed in the client’s medical record. Text messages may also be printed and stored as part of the medical record.

E. Confidentiality & Security: Clients/parents/legal guardians should not use email or text for sharing sensitive medical information. While DMV Medical Group takes reasonable precautions, DMV Medical Group is not liable for breaches of confidentiality caused by the client or any third party.

F. Follow-Up Responsibility: It is the client’s/parent’s/legal guardian’s responsibility to follow up and/or schedule an appointment if further discussion or care is needed.

G. Billing for Non-Face-to-Face Services: If an established client or their guardian initiates a non-face-to-face communication requiring medical evaluation or management via telephone, this service may be subject to billing.

General Consent for Treatment

I, the undersigned, voluntarily consent to routine evaluation, treatment, and related services provided by DMV Medical Group, LLC, including but not limited to:

  • Medical evaluations

  • Psychological services

  • Medication management services

I acknowledge that:

  • No guarantees have been made regarding the results of my evaluation or treatment.

  • The purpose of this consent has been explained to me to my satisfaction.

  • I understand the contents of this consent.

Authorization to Release Protected Health Information (PHI)

Protected Health Information (PHI) includes any information that identifies me and relates to my past, present, or future physical or mental health condition, including billing records. PHI also includes health information created or received by DMV Medical Group, LLC.

I understand that DMV Medical Group may use and disclose PHI for the purposes of:

  • Treatment (coordinating care with other healthcare providers)

  • Payment (billing insurance companies or third-party payers)

  • Healthcare operations (quality assessments, audits, and compliance activities)

I acknowledge that my PHI may be used and disclosed without my authorization as permitted by law.

If you have any questions or concerns, please contact our office directly.