Authorization and Consent to Send Unencrypted Patient Information by Email or Other Electronic Means

Until I tell you in writing to stop, I authorize Dr. Barbara Fodero to transmit patient information relating to my treatment, health, or payment by email, or other electronic means, without encryption or special security precautions, to me or someone I designate, or to other health care providers, health plan and others involved in my treatment, payment for my treatment, or Dr. Barbara Fodero’s health care operations. The patient information that may be emailed may include my x-rays, health history, diagnosis, treatment, and payment records.

I understand that:
  • I do not have to sign this form.
  • My treatment, payment, enrollment and eligibility for benefits will not be affected by my decision about signing this form.
  • If I don’t sign this form, Dr. Barbara Fodero may use other ways to send my information, such as U.S. mail, or may ask me to send my information to third parties myself.
  • There is some risk that emails or other electronic messages may be improperly acquired by hackers or received by unintended recipients. If that happens, the information may be redisclosed and no longer protected by privacy law.
  • Dr. Barbara Fodero does not email such sensitive personal information as social security number, credit card number, mental health diagnosis, genetic information, alcohol/substance abuse, or positive HIV status unless the patient insists.
I can tell you in writing to stop emailing my patient information at any time, but if I do so, this will not affect emails that Dr. Barbara Fodero already sent before receiving my written instructions to stop.
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