Patient Authorization for Email Communications

 I authorize BridgeCare Specialists to communicate with me and my providers via unencrypted email. Completing this form is needed to document my approval to permit a provider/program to communicate with me via unencrypted email.  I understand that communications over the Internet or use of an email system may not be secure. There is no assurance of confidentiality when communicating via email.


Please be advised that:

• This request applies only to the healthcare provider team through BridgeCare. If you would like to request to communicate via unencrypted email with another health care provider or program, a separate form is required.

• An email address must be provided.

• A test email is recommended before corresponding via email.


I understand and agree to the following:

• The email address provided is accurate and that I accept full responsibility for messages sent to or from this address.

• I understand and acknowledge communications over the internet or using unencrypted email may not be secure and there is no assurance of confidentiality of information communicated via email.

• I understand that email communications may be forwarded to other providers for purposes of providing treatment to me.

• I agree to hold BridgeCare Specialists and individuals associated with it harmless from any and all claims and liabilities arising from or related to this request to communicate via email.