PHI Communication Consent 

I understand that under the Health Insurance Portability and Accountability Act of 1996, I have the right to make  reasonable requests to receive confidential communications of my protected health information from BodyLuxe LLC (“Practice”) by alternative means or at alternative locations. By completing and signing this form, I am requesting Practice communicate with me via email, phone or text on the accounts listed above.

SECURITY RISKS 

Most standard email providers and phone service providers do not provide a secured or encrypted means of communication. As a result, there is a risk that any protected health information contained in an email or text may be disclosed to, or intercepted by, unauthorized third parties. Additionally, email or text messages accessible through personal computers, laptops, or phones have inherent privacy risks especially when the email account or phone is provided by an employer, when the account is not password protected, or the account is shared. Use of more secure communications, such as phone, fax or mail is preferred and always an available alternative.

RESPONSIBILITY 

When consenting to the use of email or text through such unsecured or unencrypted systems, you are accepting responsibility for any unauthorized access or disclosure to protected health information contained within the message. The Practice will not be responsible for unauthorized access of protected health information while in transmission and will not be responsible for safeguarding information once it is delivered. The Practice will take steps to ensure that any email with protected health information is protected prior to being sent to the requested address or phone and will use the minimum necessary amount of protected health information when communicating with you.

ADDITIONAL INFORMATION 

It is important to understand that emails or text will not be used to replace or facilitate communications between you and your physician and will not be considered private communications. There is no guarantee that the Practice will be actively monitoring the email or phone message inboxes so responses and replies sent to or received by you or the Practice may be hours or days apart. Email or text messages may be inadvertently missed or errors in transmissions may occur. The Practice will not be responsible for any issues caused by delays in communications. If you have an immediate need or an emergency, you must dial 911. You hereby understand that the Practice does not provide emergency services. Practice staff will be utilized to monitor the inbox in order to properly direct or respond to communications received. Therefore, any information considered sensitive should not be included in your communications. At the Practice’s discretion, any email  or text message received or sent may become part of my medical record.

I acknowledge and agree to the following:

• I have received had an opportunity to ask questions by calling the practice at 1-312-999-5505 and have had such questions answered to my satisfaction; and understand the information contained within this notice.

• Despite the possibility that my email or phone system may not be encrypted or secure and there are no assurances of confidentiality, I consent to the Practice communicating/sending photos to me via email or phone.

• The email address and phone above is accurate and it is my responsibility to update the Practice of any changes.

I may withdraw this consent at any time by delivering written notice to the Practice.