CONSENT TO EMAIL PROTECTED HEALTH INFORMATION

CONSENT TO EMAIL PROTECTED HEALTH INFORMATION

Acclaim Autism. 2929 Arch St, Suite 1700 Philadelphia PA 19104
Important. Please read this carefully: The Health Insurance Portability and Accountability Act (HIPAA) was passed by the U.S. government in 1996 in order to establish privacy and security protections for health information. Information stored on our computers is encrypted, including information stored in our company email. However, most popular free email services used by customers is not secure since they do not utilize encrypted email.

When we send you an email, or you send us an email, the information that is sent is not encrypted. This means a third party may be able to access the information and read it since it is transmitted over the internet. In addition, once the email is received by you, someone may be able to access your email account and read it.

Since email is still popular and convenient, the HIPAA act and the federal government provided guidance on email use. The guidelines state that if a patient has been made aware of the risks of unencrypted email, and that same patient provides consent to receive health information via email, then a health entity may send that patient personal medical information via unencrypted email.

By default, we will not email any protected health information (PHI) unless a pateint 18 years of age or older or a parent or legal guardian has been made aware of the aforementioned risks and agrees to receive unencrypted email from us containing protected health information. If you do not want us emailing unecrypted protected health information, do not sign this form. This form is HIPAA-compliant.
Parent / Guardian Name:*

First NameLast Name
Parent / Guardian E-mail to Receive Protected Health Information:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
List Any Other Email Addresses You Authorize Us To Email Protected Health Information For the Above Patient:
Authorization*

I understand the risks of unencrypted email and do hereby give permission to Acclaim Autism to send protected health information using unencrypted email to the email addresses above, for the above-mentioned patient. I understand to withdraw this authorization I will need to provide written notice of five days to process the request. I further confirm that I am legally permitted to consent for this patient's healthcare. I also understand I can choose to receive a copy of this form, as well as any other forms, in a paper format instead of digital by contacting Acclaim Autism by phone or fax.
Signature*

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