CONSENT TO UNENCRYPTED COMMUNICATION

I consent to OrthoMidwest, PLLC, d/b/a Ortholllinois transmitting my medical information electronically using unencrypted email or text message, as described in more detail below.

I recognize and acknowledge that unencrypted messages create the risk that my medical information will be viewed or downloaded by third parties, and I accept this risk in order to receive more efficient medical care or communications The following are examples of the risk that unencrypted messages may create:

• If my medical information is emailed to a computer that I share with others, or that is provided by my employer, the message could be opened and viewed by them.
• It is possible that others could intercept and obtain my medical information, because texting and emailing are not secure methods of communication.
• If I lose the computer, phone, or other device that is used to receive my unencrypted medical information, it will be accessible to whomever finds the device.

I consent to unencrypted communication via SMS and/or MMS text messaging and emailing to my personal email address.

I consent to receiving photographs taken of me, messages between Orthollinois medical providers and staff, such as Instructions about my care or information about my location and Information from my medical record, up to and including my entire medical record.

I understand that I may revoke this Consent at any time and for any reason. I also understand that I am not required to sign this Consent, and I will not be denied treatment or any other medical benefits if I refuse to sign this Consent. I may revoke this consent by sending written notice to the Ortholllinois Privacy Officer using the contact information in the Orthollinois Notice of Privacy Practices.