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. "
"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 Policy for E-Mail Correspondence.
Read the full Policy for Video-Conferencing and Audio-Conferencing
Instructions
Please read this entire page first, including the Alert for E-Mail Correspondence below.
There are two versions of the Email Authorization form:
The PDF format can be printed on your printer, completed by hand, signed, and then mailed or faxed to your health care provider. You can also scan the completed document and email it to your provider. Go to PDF form.
The On-line format is completed electronically (you enter your information into the form on your computer); your data is stored in a secure database*; and then you "sign" the authorization using your mouse. Your signature is attached to the document and the completed authorization is sent automatically to your provider and to you.
Go to On-line form
NOTE: There will be a $5.00 charge for this service in the near future, payable by credit card, debit card or Paypal. For now, until further notice, the service is free.
Choose one of the formats above and complete the Authorization Form : Fill in all the requested information. Items with an asterisk (*) are required.
If you don't know or can't remember your doctor or care-giver's email address, go to the UF Directory to look it up.
Browsers: The on-line authorization form is best accessed through Internet
Explorer.
Alert for E-Mail 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: |
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The following confidentiality statement is recommended for inclusion in all e-mails between patients 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. " |
Please contact Everall Peele, Privacy
Training Coordinator at epeele@ufl.edu or 352-273-5096,
if you have any questions or problems.
* The software and the database for this 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.
