I authorize Valley Foot & Ankle Center to release my doctor’s note / medical
records via email. I have read and agreed the risks of
communicating (listed below) via email.
EMAIL MAY NOT BE RELIABLE, SECURE, OR PRIVATE. IF YOU WANT
HEALTH INFORMATION TO BE SENT VIA EMAIL, PLEASE READ THE
FOLLOWING INFORMATION ON THE RISKS OF RECEIVING EMAIL
RISKS OF USING EMAIL to receive your health records:
• Email can be hacked. (Unauthorized people can intercept it, alter it, or use it).
• Email can be sent to the wrong person, lost, or subject to other sending errors.
• Email may come from someone other than the named sender.
• Email is easier to fake than handwritten, signed papers.
• Anyone with access to an email account will have access to all messages in that account. This includes those who have permission to use the email account as well as those who don’t.
• Anyone who gets or has access to an email can read, forward, copy, delete, or change it. This includes those who have permission to use the email account as well as those who don’t.
• Any deleted emails can be found again.
• E-mail services have a right to save and check e-mail sent through their system.
• E-mail can spread viruses.
• You should not receive your health information via email if people who you don’t want to view your medical information have access to your email account.
If you are requesting that your information be sent to you or another
person by email, you further acknowledge and agree to the risks of
transmitting and receiving your information by email, as disclosed in
paragraph one of this form and you agree to release and hold harmless
Valley Foot & Ankle Center from any liability that may result from using
email to communicate with you or another person you may have designated
to receive emails that include your Health Information. This includes, but is
not limited to, breaches of confidentiality or privacy that may come from
using e-mail (except as required by law).