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Authorization to Use or Disclose Protected Health Information via Unencrypted Electronic Means

You have the right to request that protected health information about you that is maintained by the UNC-Chapel Hill Psychology and Neuroscience Department Community Clinic (“Clinic”) be sent to you via unencrypted means. Before transmitting this information, UNC-Chapel Hill must first advise you of the risks associated with transmitting via unencrypted means. Please review the “Alert for Electronic Communications” below in which we notify you of these risks. If after reviewing the Alert you decide you want to communicate via unencrypted means, then complete the Authorization below and we will transmit/accept transmission of your protected health information (PHI) in that manner. UNC-Chapel Hill is not responsible for the unauthorized access of PHI while in transmission based on your request and is not responsible for safeguarding information once delivered to you.

Alert for Electronic Communications

Patients and/or Designated Legal Representatives or Guardians who communicate with UNC-Chapel Hill Workforce Members, including UNC-Chapel Hill faculty, staff, students, fellows, volunteers, trainees, agents, contractors, and/or affiliates, whether paid or unpaid, who work or train in UNC-Chapel Hill units that create, receive, maintain, or access PHI or other sensitive information, by unencrypted e-mail or text message should carefully consider all of the following issues before signing the Authorization to Use or Disclose Protected Health Information via Unencrypted Electronic Means:

  1. The decision to communicate with you by email and/or text message is for convenience purposes.
  2. Email and text messages sent to you by Workforce Members of UNC-Chapel Hill will not be encrypted during transmission (unless otherwise indicated).
  3. Messages sent using a third-party email, cellular phone, or internet company may be stored on the third-party’s platform in accordance with their security/privacy controls which may not fully protect your information included in the email or text message.
  4. It is possible that unencrypted emails and text messages can be forwarded, intercepted, printed, and/or stored by others.
  5. Emails and text message communications are a convenience and not appropriate for emergencies or time-sensitive issues. In case of an emergency, please call your provider’s office, call 911, or go to the nearest Emergency Room.
  6. Highly sensitive or personal information should not be communicated by email or text message (i.e., HIV status, mental illness, chemical dependency, and workers compensation issues). Be cautious when sending any sensitive personal or medical information in your messages.
  7. Employers generally have the right to access any e-mail received or sent by their employees via their work email. This may also be true for text messages you send if the recipient is using a company owned cellphone. If you use your work email address to send/receive emails from your UNC-Chapel Hill provider or use a work phone to send/receive text messages, then it is possible that your messages may be viewed and stored by your employer.
  8. Emails and text messages sent to UNC-Chapel Hill may be viewed and read by staff other than the health care provider to whom you sent the email or text message.
  9. Clinically relevant messages and responses may be documented in your official medical record, where applicable.
  10. If you change your email address or phone number, it is your responsibility to inform your provider or the care team with whom you have been communicating that you have an updated email address or phone number.
  11. UNC-Chapel Hill will not reimburse you for any expenses associated with sending or receiving text messages. If you are concerned about fees from your cellular provider incurred as a result of sending or receiving text messages, please do not sign this authorization. If you have already signed it, you may cancel your authorization by contacting your provider or treating team at UNC-Chapel Hill (or such other party you are communicating with via email or text) to inform them of your intent to cancel this Authorization.
  12. UNC-Chapel Hill is not liable for lost information or misdirected messages due to technical errors or failures.