Healthcare Patient Consent to Email

HEALTHCARE PATIENT CONSENT TO EMAIL

Patient Name:    Provider Name:

Patient Information

Insurance Information

Medical History (Relevant to Email Communications)

Authorization to Communicate via Email

I hereby authorize the Provider named above to communicate with me at the email address provided above for the purposes indicated below. I understand that email communications may include protected health information and that there are risks associated with transmitting health information by unencrypted email.

Scope of authorized communications (check all that apply):

Appointment reminders and scheduling

Laboratory, imaging, and diagnostic test results

Billing statements and insurance correspondence

Clinical summaries and progress notes

Referral information and communications with outside providers

Other:

I understand and accept the following risks and conditions:

1. Emails may be intercepted, misdirected, or accessed by unauthorized third parties if not encrypted.
2. The Provider will use reasonable safeguards to protect confidentiality but cannot guarantee security of standard email.
3. I will notify the Provider promptly if my email address changes or if I suspect unauthorized access to my email account.
4. I may withdraw this consent at any time by providing written notice; withdrawal will not affect messages sent prior to the Provider's receipt of the withdrawal.

Alternatives to email communications include telephone calls, postal mail, secure patient portal messaging, and in-person communications. If I prefer encrypted email only, I request:

Authorization effective date: . Authorization expiration date (if any): . If no expiration date is provided, this authorization will remain in effect until revoked in writing.

HIPAA / Privacy Acknowledgment

I acknowledge that I have received and reviewed the Provider's Notice of Privacy Practices and understand how my health information may be used and shared in connection with email communications.

Patient Responsibilities and Certification

By signing below, I certify that I am the patient or am authorized to act on behalf of the patient, that I have read and understand this authorization, that I have been informed of the risks and alternatives to email communications, and that I consent to the Provider communicating with me at the email address provided for the purposes checked above.

I understand that any email communications sent pursuant to this authorization will be included in my medical record and may be subject to release in response to legal process as permitted by law.

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