Authority to Release Medical Information via Email Form

By signing the “Authority to release medical information via email” form, you are giving Mt Barker & Balhannah Medical Clinics consent to release medical records, reports and/or statements from your treating medical practitioner via an insecure communication platform.

Authority to Release Medical Information via Email Form

Understand the following:

  • An email can be forwarded or changed without the knowledge or permission of the original sender.
  • The email is not encrypted.
  • Exchanging records by unencrypted email is vulnerable to interception and hacking by unauthorised third parties.
  • Emails can be accessed on portable devices
  • The email service may not be able to handle the file sizes these images require.
  • I have considered communicating any sensitive information by telephone, fax, or mail.
  • There is the possibility of human error when manually typing in e-mail addresses.

I hereby authorise Mt Barker Balhannah Medical Clinics to provide my medical records via email and I only need to fill this form out once as blanket consent. I will notify Mt Barker Balhannah Medical Clinics when I wish to cease my health information being sent by email.