Unsecured email Consent

To initiate this request you must first call our office and verify your identity.

If you are requesting South Suburban Family Medicine to release your protected health information via unsecured email please use this form to provide consent (HIPPA waiver). Information communicated via standard email is unsecured, unencrypted and can potentially be accessed by others. We want to be certain that you understand the risks before providing consent to use the email address you provide. Be sure to specify the health information (labs, dates, etc…) you are requesting.