Until I tell you in writing to stop, I authorize Eric Groeneveld DDS, P.C. to transmit patient information relating to my treatment, health, or payment by email or other electronic means, without encryption or special security precautions, to me or someone I designate, or to other health care providers, health plans and other involved in my treatment, payment for my treatment, or Eric Groeneveld DDS, P.C. health care operations.  The patient information that may be emailed may include my x-rays, health history,  diagnosis, treatment, and payment records.

I understand that:

• I do not have to sign this from
• My treatment, payment, enrollment and eligibility for benefits will not be affected by my decision about signing this form. 
• If I don’t sign this form, Eric Groeneveld DDS, P.C. may use other ways to send my information, such as U.S. Mail, or may ask me to send my information to third parties myself.
• There is some risk that emails and other electronic messages may be improperly acquired by hackers or received by unintended recipients.  If that happens, the information may be redisclosed and no longer protected by privacy law. 
• Eric Groeneveld DDS, P.C. does not email such sensitive personal information as Social Security number, credit card numbers, mental health diagnosis, genetic information, alcohol/substance abuse, or positive HIV status unless the patient insists.

 I can tell you in writing to stop emailing my patient information at any time, but if I do so, this will    not affect emails that Eric Groeneveld DDS, P.C. already sent before receiving my written instructions to stop.