Request for transmission of protected health information by non-secure means

Form Template for Hush™ Secure Forms

About Hush™ Secure Forms

Hush™ Secure Forms is our secure, digital alternative to old-fashioned paper forms. You can launch a beautiful, personalized web form for your business in minutes with our drag-and-drop form builder, template directory, and built-in secure web hosting.

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Request for transmission of protected health information by non-secure means

This form allows your clients to use or not use non-secure communications and informs them of the risks.

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Try Hush™ Secure Forms risk-free for 60 days

Hushmail for Healthcare includes Encrypted Email and a Private Message Center with optional Secure Forms and Electronic Signatures. We'll include a signed Business Associate Agreement (BAA) and Email Archiving to help with your HIPAA compliance.

Black Friday Sale

Get 50% off your first 3 months

Applies to all monthly heathcare plans
Hurry! Offer ends on December 1st

Starter

$
11.99
$
5.99
per month
for 3 months
$
5.99
per month

Recommended

$
24.99
$
12.49
per month
for 3 months
$
12.49
per month

Custom

Speak to Sales for custom pricing
Encrypted email accounts 1 Up to 5
Up to
Secure web forms Not included Up to 5
Up to
Electronic signatures Not included Included Included
HIPAA-Compliant Service Included Included Included
Done-For-You Form Building Service $25 per form built Not included Not included $25 per form built Up to 2 forms Up to 2 forms $25 per form built Up to 5 forms Up to 5 forms
60-day money back guarantee Included Included Included
Available plan add-ons (purchase during checkout)
Add 1 email
+$5/mo
+$5/mo

+$2.50/mo
Add 3 forms
+$3/mo
+$3/mo

+$1.50/mo
Add 1 email
+$55/yr
Add 3 forms
+$33/yr
Add 1 email
+$105/2 yr
Add 3 forms
+$63/2 yr
Add 1 email
and form
+$5/mo
+$5/mo

+$2.50/mo
Add 1 email
and form
+$55/yr
Add 1 email
and form
+$105/2 yr
Encrypted Email
Webmail (desktop & mobile) Included Included Included
Works with email apps (e.g. Outlook) Included Included Included
Hushmail for iPhone Included Included Included
Custom domain (@yourcompany.com) Included Included Included
Send & receive encrypted file attachments Included Included Included
Email aliases Unlimited Unlimited Unlimited
Storage (per email account) 10 GB 15 GB 10 GB
Secure Web Forms
Monthly form submissions Unlimited Unlimited
Maximum pages per form Unlimited Unlimited
Ready-made form templates With add-on Included Included
Calculated questionnaires (e.g. PHQ-9) With add-on Included Included
Design your own forms With add-on Included Included
Receive form submissions as PDFs With add-on Included Included
Conditional field visibility With add-on Included Included
Share forms with colleagues Not included Included Included
Body charts Not included Included Included
Electronic Signatures
Sign on desktop and mobile Not included Included Included
Detailed activity records Not included Included Included
ESIGN and UETA compliant Not included Included Included
One signer per form Not included Included Included
Multiple signers per form Not included Not included Coming soon
Private Message Center
Maximum clients per month Unlimited Unlimited Unlimited
Clients can send secure replies Included Included Included
Clients can sign in with their Google, Apple, or Microsoft account Included Included Included
Customization & Branding
Custom logo Not included Included Included
Custom secure web form accent color Not included Included Included
Remove Powered by logo from forms Not included Not included Included
Customer Care
One-on-one setup assistance by phone Included Included Included
Technical support by phone and email Included Included Included
Online knowledge base Included Included Included
Security & Compliance
Business Associate Agreement HIPAA Included Included Included
Email archiving HIPAA Included Included Included
Information Manager Agreement (Canada) Included Included Included
Two-step verification Included Included Included
Encryption OpenPGP & SSL OpenPGP & SSL OpenPGP & SSL
Domain Administration (if using a custom domain)
Standard email forwarding Included Included Included
Catch-all email forwarding Included Included Included
Manage user accounts Not included Included Included
Expand all features

All prices displayed are in US dollars. Taxes may apply. Full refund if you cancel within 60 days.

Hushmail for Small Business includes Encrypted Email, Secure Web Forms, a Private Message Center, and optionally Email Archiving.

All prices displayed are in US dollars. Taxes may apply.

Hushmail for Law includes Encrypted Email, Secure Web Forms, a Private Message Center, and Email Archiving. Plus, we'll sign an agreement with customers in the U.S., Canada and the U.K. to seek judicial protection for the account, if necessary, on the basis that the contents are privileged, providing extra protection for your communications.

All prices displayed are in US dollars. Taxes may apply.

Hushmail for Personal Use includes Encrypted Email and a Private Message Center, with an email address ending in , , , or . Custom email domains are not available on this plan.

The price displayed is in US dollars. Taxes may apply.

From the Blog

Is Google Drive HIPAA compliant?

Published on June 29, 2023

Is Google Drive a safe place to store client data? Learn about its potential risks and how to stay HIPAA compliant in healthcare with this guide. Read more.

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