Email Consent Form Email Consent Form PATIENT REQUEST AND CONSENT TO RECEIVE PROTECTED HEALTH INFORMATION (PHI) VIA EMAIL Authorization to Communicate Protected Health Information via EmailPatient InformationPatient Name(Required) First Last Patient Date of Birth(Required) MM slash DD slash YYYY Email Address for Communication(Required) Email Address Confirm Email Address Please note: This consent applies only to the email address listed above and only to the patient records specified in this consent. A separate consent is required for records containing PHI to be sent to any other email address or for the release of additional records. Patient Consent for Email Communication of Protected Health Information (PHI)Email is not a secure form of communication. Standard email services may not use encryption, which means there is a risk that your protected health information (PHI) could be accessed by unauthorized individuals while in transit. Despite these risks, you may choose to authorize us to send your health information via email. By completing this form, you acknowledge that you have been informed of the risks and consent to email communication under the conditions outlined below.Please read and check EACH box to indicate your understanding and consent:(Required) I understand that email is not a secure method of communication and may not be encrypted. I acknowledge that there is a risk that my PHI could be accessed by unauthorized individuals during transmission. I accept these risks and request that Indiana Health Group send my health information to the email address I have provided. I understand that Indiana Health Group is not responsible for unauthorized access to my PHI that occurs during or after transmission due to the nature of email communication. I understand that I may revoke this consent at any time by submitting a written request, but that any information sent prior to the revocation is not affected. Select AllAll boxes must be checked for this form to be valid.Signature of Patient, Parent, or Legal Representative:(Required)By completing this form, you acknowledge that you have been informed of the risks and consent to email communication under the conditions outlined below. Printed Name(Required) First Last Relationship to PatientDate(Required) MM slash DD slash YYYY
