HIPAA Email Consent for Document Upload/Request

HIPAA Email Consent for Document Upload/Request
Waggoner Pediatrics of Central Iowa
2555 Berkshire Pkwy, Ste A, Clive, IA 50325
Phone: 515-987-0051

We prioritize the privacy and security of your health information in accordance with the Health Insurance Portability and Accountability Act (HIPAA). At your request, we can return completed forms via unencrypted email, or we can send specific forms we have on file for your child. Please read the information below and provide your consent to receive the requested document via unencrypted email. Please allow 2-3 business days for the requested documents to be returned to you. We appreciate your understanding!
Patient Information
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Today's Date

MonthDayYear
Date
Age
Document Request Options

Please select one of the following options:
Request a Form To Be Completed & Returned*

Iowa Immunization CertificateSchool Medical Report (Latest Well Visit)Iowa Athletic Pre-Participation Physical Examination (Latest Well Visit)Lab ResultSchool Excuse Note (Please also select "Other" below and List Dates Needed on Excuse Note)Patient Uploaded Form (See Below)Itemized Payment Receipt (Please also select "Other" below and List Date of Service)Other
Upload a Form for Completion

If uploading a document, please check "Patient Uploaded Form" above in the Option 1 Section.
Cancelof
Waiver Agreement for Form Delivery

I understand that email communications are not encrypted and may be intercepted, accessed, or viewed by unauthorized individuals. Despite these risks, I request to receive the document I have either uploaded or selected above via unencrypted email from Waggoner Pediatrics.

By signing this waiver, I acknowledge the following:
1. Risks of Email Communication: I am aware that email communications are not guaranteed to be secure and could be accessed by unauthorized individuals during transmission. There is a risk that PHI contained within the requested document could be disclosed to third parties.
2. Specific Consent for Uploaded or Requested Document: I voluntarily consent to receive the document I am either uploading or requesting from Waggoner Pediatrics via unencrypted email.
3. Right to Withdraw Consent: I understand that I may revoke this waiver at any time by notifying Waggoner Pediatrics in writing. Upon revocation, Waggoner Pediatrics will cease to use email to return forms or documents to me via unencrypted means.
4. Alternative Secure Communication: I have been informed that secure, HIPAA-compliant methods of communication (e.g., patient portal) are available, and I have chosen to waive these options in favor of receiving the specified document via unencrypted email.
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Email (where you want the completed form sent)*
example@example.com
Patient Name*

First NameLast Name
Patient Email (where you want the completed form sent)*
example@example.com
Parent/Guardian Signature*

Powered by Jotform SignClear
Patient Signature*

Powered by Jotform SignClear
Acknowledgment of Receipt of HIPAA Notice

By signing above, I acknowledge that I have received a copy of Waggoner Pediatrics’ HIPAA Notice of Privacy Practices and understand the potential risks associated with unencrypted email communication.
Submission of This Form

By submitting this form, I confirm that I have read and understand this waiver and consent to receive the requested document via unencrypted email.
Should be Empty:

HIPAA Email Consent for Document Upload/Request

Waggoner Pediatrics of Central Iowa2555 Berkshire Pkwy, Ste A, Clive, IA 50325Phone: 515-987-0051

Patient Information

Document Request Options

Waiver Agreement for Form Delivery

Acknowledgment of Receipt of HIPAA Notice

Submission of This Form

Waggoner Pediatrics of Central Iowa
2555 Berkshire Pkwy, Ste A, Clive, IA 50325
Phone: 515-987-0051