HIPAA POLICY FOR UNSECURED EMAIL TRANSMISSION
As a patient of Villages Smiles, I understand that email communication may not be a secure method of transmitting protected health information (PHI). While Villages Smiles takes reasonable precautions to protect the confidentiality and security of PHI transmitted via email, there is a risk that email messages could be intercepted, accessed or disclosed without my authorization.
I acknowledge that I have been informed of the risks of unsecured email transmission and that Villages Smiles may use email to communicate with me regarding my healthcare. I understand that this information will be distributed via email, which may include my PHI.
I agree to the use of unsecured email transmission to communicate with Villages Smiles for the purposes of my healthcare. I understand that I have the right to revoke this consent at any time by providing written notice to Villages Smiles. I also understand that I have the right to request an alternative method of communication and that Villages Smiles will accommodate this request to the extent possible.
I acknowledge that I have been given the opportunity to ask questions regarding the use of email to communicate my PHI and that my questions have been answered to my satisfaction. I understand that I am not required to provide my consent to use email to communicate my PHI, and that I may choose to communicate with Villages Smiles by other means if I prefer.
By signing below, I acknowledge that I have read and understand this policy and that I agree to the use of email to communicate with Villages Smiles for the purposes of my healthcare.