HIPAA Email Release Authorization

HIPAA Email Release Authorization

Authorize Physical Therapy Associates of New York to send your PHI via email after acknowledging the risks.
Patient Full Name

First NameLast Name
Patient Email Address
example@example.com
Authorization Statement:

I, {q2_fullname0}, request that Physical Therapy Associates of New York send the document containing my PHI to me via email at {q3_email1}.

I understand that email is not a HIPAA-compliant method for transmitting PHI and that there are risks of unauthorized access or interception. I accept these risks and release Physical Therapy Associates of New York from any liability related to sending my PHI by email.

Signed:
{q2_fullname0}
{q6_datetime4}
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty: