ZOE Integrated Wellness, PLLC
Last Updated: [Insert Date]

This policy explains how ZOE Integrated Wellness, PLLC manages social media, digital communication, and online interactions to protect your privacy and maintain professional boundaries.

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1. Social Media Boundaries

• Providers do not accept friend requests or follow clients on personal social media accounts.

• Providers will not interact with clients on social media platforms.

• Clients are discouraged from posting public comments or reviews that reveal their treatment relationship.

2. Electronic Communication

• Email and text messaging may be used for administrative purposes only, such as scheduling.

• Clinical discussions should occur during sessions or through secure messaging.

• Providers do not offer therapy via social media, direct messaging, or unsecure platforms.

No mobile opt‑in or text message consent will be shared with third parties or affiliates.

3. Online Reviews

Clients may leave reviews voluntarily, but providers cannot respond due to confidentiality laws.
A lack of response does not indicate agreement or disagreement.

4. Telehealth Platforms

Telehealth is conducted only through secure, HIPAA‑compliant platforms.

5. Emergencies

Electronic communication is not monitored continuously.
For emergencies, call 911 or go to the nearest emergency room.

RELEASE INFORMATION (ROI) FORM

ZOE Integrated Wellness, PLLC

This form authorizes ZOE Integrated Wellness, PLLC to release or obtain protected health information (PHI) as specified below.

 

1. Client Information

Client Name: __________________________________
Date of Birth: _________________________________
Phone Number: _________________________________

2. Recipient of Information

I authorize ZOE Integrated Wellness, PLLC to:
☐ Release information to
☐ Obtain information from

Name/Organization: _____________________________
Address: _______________________________________
Phone: _________________________________________
Fax: ___________________________________________

3. Information to Be Released

(Check all that apply)

☐ Treatment summary
☐ Diagnosis
☐ Progress notes
☐ Medication information
☐ Attendance verification
☐ Entire record
☐ Other (specify): ________________________________

 

4. Purpose of Disclosure

☐ Coordination of care
☐ Legal purposes
☐ Insurance
☐ Personal use
☐ Other: _________________________________________

 

5. Expiration

This authorization expires on:
Date: __________________ OR
☐ At the end of treatment
☐ One year from the date signed

 

6. Your Rights

• You may revoke this authorization at any time in writing.

• Revocation does not apply to information already released.

• Refusal to sign will not affect your ability to receive services.

• Information disclosed may no longer be protected once released to a third party.

 

7. Signature

Client Signature: _______________________________
Date: ___________________

Parent/Guardian (if applicable): __________________
Relationship: ___________________

Provider Signature: _____________________________
Date: ___________________