Email Authorization Form

7789 Southwest Fwy, Suite 400, Houston, TX 77074 I(832) 649-4273

Authorization to Release Information to Family Members

Many of our patients allow family members such as their spouse, significant other, parents or children to call and request the result of tests, procedures and financial information. Under the requirements for H.I.P.A.A. we are not allowed to give this information to anyone without the patient's consent. If you wish to have your medical information, any diagnostic test results and/or financial information released to any family members you must sign this form.

I authorize SOUTHWEST WOMANCARE OBGYN PLLC to release my records and any information requested to the following individuals.

1. Name*

Relationship to Patient*

2. Name

Relationship to Patient

Authorization Regarding Messages (please check all that apply)

I authorize you toleave a detailed message on my home or cell number regarding appointments.I authorize you to leave a detailed message on my home or cell number regarding medical treatment, care, test results or financial information.

Email Communication

It is often convenient to communicate with one another via email for scheduling surgery or brief updates on information. Detailed emails with clinical information should be limited in use. It is important you understand that email communication between us is not encrypted and, therefore, not secure communications. If you choose to communicate with our office from your workplace computer, you should be aware that your employers and its agents may have access to your emails. Finally, email communications may become part of your medical record. Email communication should never be used in case of an emergency or urgent requests.

___ YES, I consent to receive email communication from Southwest WomanCare OBGYN (Including PatientPortal usage.)

Email

example@example.com

___ NO, I prefer NOT to have email usage or the use of the patient portal with Southwest WomanCare OBGYN.

Date

Print Name*

Date of Birth*

Date

Signature*