E-MAIL/FAX WAIVER POLICY

It is generally a policy of this office not to communicate Protected Health Information (PHI) and Health Insurance Portability and Accountability (HIPAA) sensitive information through email. However, we know in certain situations, it may be the only form of communication available. E-mail communications from our office are NOT secure and thus are not HIPAA compliant. Unsecured e-mail is at risk of being intercepted by an unauthorized third-party. To email PHI and HIPAA sensitive information through an unsecured channel, we need your informed consent. Even with consent, Physicians Now Urgent Care reserves the right to use other forms of communication if we deem warranted.

Exception to this policy:
We do not send sensitive lab results through e-mail. They must be picked up in person or through a visit with a provider.

Please INITIAL ONLY ONE selection:

Physicians Now, LLC has made me aware of the risks associated with sending PHI through unsecured e-mail. I give my consent to have PHI e-mailed to me despite the risk.
Physicians Now, LLC has made me aware of the risks associated with sending PHI through unsecured e-mail. I DO NOT give my consent to have PHI e-mailed to me despite the risk.

Print Patient First Name:

Print Patient Last Name:

Email Address:

Date: