Signup For Email Communications Form

Email communication containing protected health information (PHI) may take place between Northwest Indiana Community Action Corporation and a client if both parties agree on this communication method and this form is completed and signed by the client or the client's personal representative (if appropriate).

This agreement is limited to communications using the email address below.

Please note that most standard email does not provide a secure means of communication. There is some risk that any protected health information contained in email may be disclosed to, or intercepted by, unauthorized third parties. Use of more secure communications, such as phone or fax is an alternative that is available to you

By completing this form, NWICA and I understand and are willing to accept the risks involved with insecure email communication of my protected health information.