Authorization for Electronic Communications
"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:
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
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:
Please contact Everall Peele, Privacy
Manager at firstname.lastname@example.org 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.