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I hereby acknowledge that this form is unencrypted and not a secure means of electronic communication with, Surgical Associates of Collin County, my healthcare provider or facility. I agree to allow Surgical Associates of Collin County or facility staff to reply to the email address indicated on this form, and to forward or share the information contained in this form, including any Personal Health Information (PHI), with other health professionals or associated staff using non-secure electronic communication methods such as email.