PATIENT REQUEST FOR UNENCRYPTED EMAIL COMMUNICATIONS
Under the Health Insurance Portability and Accountability Act (HIPAA), you have the right to receive treatment information and communications by unencrypted email at an address provided below.
However, please note that these communications will not be encrypted, and therefore may not be secure. Email has numerous privacy risks, and third parties may be able to obtain access to unencrypted emails. Because of this, we cannot provide any assurance of the confidentiality, integrity, or availability of any communication or protected health information (PHI) contained therein if you elect to receive communications by unencrypted email.
Receiving unencrypted email communications is optional and solely for the convenience of the patient and his or her guardian (if applicable). The patient can receive treatment without electing to receive unencrypted email communications.
I acknowledge my recognition and understanding of the inherent risks of communicating health information via unencrypted email and hereby consent to receive such communications despite those risks. Messages containing clinically relevant information may be incorporated into the medical record at the provider’s discretion.
I also acknowledge that I have the choice to receive communications via other more secure means such as by telephone, and agree to hold my physician, Rocket Doctor Inc. and Rocket Doctor, Inc. harmless for unauthorized use, disclosure, or access of my protected health information sent to the email address I provide.
I understand that I can choose to stop receiving unencrypted email communications at any time by emailing email@example.com.