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Email Communication of Health Information Fact Sheet and Consent Form

As a patient of  Cy Fair Pediatrics, you may request that we communicate with you via unencrypted electronic mail (email). This Fact Sheet will inform you of the risks of communicating with your healthcare provider via email. Your health is important to us and we will make every effort to reasonably comply with your request to receive communications via email, however, we reserve the right to deny any request for email communications when it is determined that granting such a request would not be in your best interest. 


Cy Fair Pediatrics staff will make every effort to promptly respond to your requests for information via email, however, if you are experiencing an emergency, you should never rely on email communications and should seek immediate medical attention. 

Risks of using email to send protected health information include, but are not limited to: 

  • Risk of Unauthorized Access by a Third Party: Do you share a computer with your family? Is your email address or access to email provided through your employer? Do you access your email over an unsecured connection such as public Wi-Fi? Do you access your email on your mobile device? Emails may be accessed by someone you do not wish to know about your health information. Despite necessary precautions, email may be sent to the wrong address by either party. Email may be intercepted or altered in transmission by a computer hacker or computer virus. 

  • Unique Difficulty in Verifying Sender: Email may be easier to forge than handwritten or signed papers. Cy Fair Pediatrics will only send emails to the email address you provide, but it may be difficult to confirm that you are in fact the person sending the request for information from your email address. 


  • Emails are not checked outside of normal business hours - this includes overnight and on weekends or holidays. 

  • Please call Cy Fair Pediatrics at 281-894-3100 or 832-688-8946 to confirm that your request was received if you haven't received a response by email or telephone within a few hours. 

  • If at any time you change your email address or wish to discontinue email communications altogether, you must notify Cy Fair Pediatrics immediately in writing. 


By signing below, you acknowledge your recognition and understanding of the inherent risks of communicating your health information via unencrypted email and hereby consent to receive such communications despite those risks.  Messages containing clinically relevant information may be incorporated into the medical record at the provider's discretion. 

By signing below, you also acknowledge that you have the choice to receive communications via other more secure means such as by telephone.  By signing below, you agree to hold Cy Fair Pediatrics harmless for unauthorized use, disclosure, or access of your protected health information sent to the email address you provide. 

PLEASE CLICK HERE TO DOWNLOAD THE FORM - Please sign and bring this to your appointment. 

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