Authorization for Electronic Communications

Email Correspondence

"E-mail between UF clinicians and patients or between UF researchers and subjects may include PHI only if the patient/subject has signed an authorization. "

Video-Conferencing or Audio-Conferencing

"Patients (or their legal guardians) whose PHI will be used or disclosed in the conference must be given time to review the Alert for Electronic Communications and ask questions, and must sign an Authorization to Use or Disclose PHI via Electronic Media prior to the conference."

Read the full policies for:
E-Mail Correspondence
Video-Conferencing and Audio-Conferencing


Please read this entire page first, including the Alert for Electronic Correspondence below.

There are two versions of the Authorization form:

1. The (preferred) On-line format is completed electronically; that is, you enter your information into the form using your computer, and then you "sign" the authorization using your mouse. Items with an asterisk (*) are required. Your signature is attached to the document and the completed authorization is sent automatically to your provider and to you.
Your data is stored in a secure database* and a copy of the form is sent anonymously to the database manager in the UF Privacy Office.
Please use a separate form for each person you would like to correspond with.
If you
don't know or can't remember your doctor or care-giver's email address, please call your caregiver's office or clinic or use the UF Directory to find it.
Go to the On-line form

2. If the online format is not working, the PDF format can be printed on your printer, completed by hand, signed, and then mailed or faxed to your health care provider. If you mail the form, be sure to make a copy for yourself before mailing. You can also scan the completed document and email it to your provider.
Go to PDF form.

Browsers: The on-line authorization form is best accessed through Internet Explorer.

Alert for Electronic Correspondence

Email Correspondence:
Patients and/or personal representatives who want to communicate with their health care providers by e-mail should consider all of the following issues before signing an Authorization to Use or Disclose Protected Health Information via Electronic Media:

  1. E-mail at the University of Florida can be forwarded, intercepted, printed and stored by others.
  2. E-mail communication is a convenience and not appropriate for emergencies or time-sensitive issues.
  3. Highly sensitive or personal information should not be communicated by e-mail (i.e., HIV status, mental illness, chemical dependency, and workers compensation issues.)
  4. Employers generally have the right to access any e-mail received or sent by a person at work.
  5. Staff other than the health care provider may read and process e-mail.
  6. Clinically relevant messages and responses will be documented in the medical record.
  7. Communication guidelines must be defined between the clinician and the patient, including:
    1. how often e-mail will be checked,
    2. instructions for when and how to escalate to phone calls and office visits, and
    3. types of transactions that are appropriate for e-mail
  8. The E-mail message must include:
    1. The subject of the message in the subject line, i.e., prescription refill, appointment request, etc., and
    2. Clear patient identification including patient name, telephone number and patient identification number in the body of the message.
  9. The University of Florida will not be liable for information lost or misdirected due to technical errors or failures.

The following confidentiality statement is recommended for inclusion in all e-mails between patients/subjects and providers:

"This communication may contain information that is legally protected from unauthorized disclosure. If you are not the intended recipient, please note that any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this message in error, you should notify the sender immediately by telephone or by return email and delete this message from your computer. "

Video and Audio Conferences:
Patients and/or personal representatives who participate in teleconferences with their health care providers should consider all of the following issues before signing an Authorization to Use or Disclose Protected Health Information via Electronic Media:

  1. Although interactive video and audio teleconferences use equipment and telecommunications lines which have been approved for secure use by the Health Science Center Information Technology Department, complete privacy and security cannot be guaranteed.
  2. Pertinent personal information, including HIV status, mental illness, chemical dependency, substance abuse, developmental, genetic, and workers compensation issues may be communicated during the teleconference.
  3. Staff other than the health care provider may have access to the teleconference recordings and transmissions.
  4. The University of Florida will not be liable for information lost or misdirected due to technical errors or failures.

Please contact the Privacy Office at or 352-273-1212, if you have any questions or problems.

* The software and the database for this authorization form are owned and operated by MarkeTech, Inc., a contracted Business Associate of the University of Florida. The information in the database is monitored by the UF Privacy Office.

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