REQUEST FOR TRANSMISSION OF PROTECTED HEALTH INFORMATION 
BY NON SECURE MEANS 

I, 

AUTHORIZE: Marsha Magun 
Creative Counseling and Coaching LLC 

431 Post Road East 
Westport, Ct 06880 

(Name of client). 

TO TRANSMIT TO ME BY NON-SECURE MEDIA THE FOLLOWING TYPES OF PROTECTED 
HEALTH INFORMATION RELATED TO MY HEALTHCARE RECORDS AND HEALTHCARE 
TREATMENT: 

· Information related to scheduling of meetings or other appointments 

· Information related to billing or payment (but not to include any financial or claims -related 
identifiers including, but not limited to, credit card numbers, diagnosis codes, or procedure 
codes.) 

TERMINATION: 

This termination will terminate __ days after the date listed below. 
OR 

this termination will terminate when the following event occurs _ 

I have been informed of the risks, including but not limited to my confidentiality in treatment, of 
transmitting my protected health information by unsecured means. I understand that I am not 
required to sign this agreement in order to receive treatment. I also understand I may terminate 
this authorization at at any time. 

I understand that Marsha Magun makes available to me the following means of communication 
that are designed to be secure and to maintain confidentiality, and still choose to request and 
authorize the above-named non- secure means: 

· Encrypted Web-site: WWW.creativecounselingandcoachingct.com 

· Secure texting app for smartphones. app: WhatsApp. 

Signature of client. 

Date