Health care providers are allowed to communicate electronically with their patients provided they apply reasonable safeguards when doing so (45 C.F.R. § 164.530c). The recipient acknowledges that communications transmitted via internet are not secure. There is a possibility that information you include in this self report form and its attachments could be intercepted and read/heard by unintended parties. Please do not include personal identifying information such as your birthdate, or personal medical information in any of the form fields. If you are not the recipient or a recipient authorized agent, you are hereby notified that any review, dissemination, distribution, or printing/copying of this self report form is prohibited. If you received this transmission in error, please notify the sender immediately at (972) 439-5751 and delete the form received.