Email Liability Release

  • Please read carefully:
    • HIPAA stands for the Health Insurance Portability and Accountability Act.
    • HIPAA was passed by the U.S. government in 1996 in order to establish privacy and security protections for health information.
    • By signing this form, you understand and agree to send and receive you and/or your family’s medical information via in an unencrypted format.
    • Free email services (ex. Hotmail®, Gmail®, Yahoo®) do not utilize encrypted email.
    • When we send you an email, or you send us an email, the information that is sent is NOT Encrypted.
    • This means a third party may be able to access the information and read it since it is transmitted over the Internet.
    • In addition, once the email is received by you, someone may be able to access your email account and steal sensitive information.
    • Email is a very popular and convenient way to communicate, however not safe.
    • The HIPAA act requires we provide options for receiving protecting health information.
    • The information is available in a pdf (page 5634) on the U.S. Department of Health and Human Services website at
    • The guidelines state that if a patient has been made aware of the risks of unencrypted email and that same patient provides consent to receive health information via email, then a health entity may send that patient personal medical information via unencrypted email.


    I understand the risks of unencrypted email and do hereby give permission to the EBS CHILDREN’S INSTITUTE to send and receive all personal health information, reported, documents, and evaluations via unencrypted email. I release EBS Children’s Institute from any further liability from the release of all Protected Health Information.

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