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Patient Name:
Patient Address:
Patient E-Mail Address:

1. Risk of Using E-Mail

We offers patients the opportunity to communicate by e-mail. Transmitting patient information by e-mail, however, has a number of risks that patients should consider before using e-mail. These include, but are not limited to, the following risks:

  • E-mail can be circulated, forwarded, and stored in numerous paper and electronic files.
  • E-mail can be immediately broadcasted worldwide and be received by many intended and unintended recipients.
  • E-mail senders can easily misaddress an e-mail.
  • E-mail is easier to falsify than handwritten or signed documents.
  • Backup copies of e-mail may exist even after the sender or the recipient has deleted his or her copy.
  • Employers and online services have a right to archive and inspect e-mails transmitted through their systems.
  • E-mail can be intercepted, altered, forwarded, or used without authorization or detection.
  • E-mail can be used to introduce viruses into computer systems.
  • E-mail can be used as evidence in court.

2. Conditions for the Use of E-Mail

We will use reasonable means to protect the security and confidentiality of e-mail information sent and received. However, because of risks outlined above, we cannot guarantee the security and confidentiality of e-mail communication, and will not be liable for improper disclosure of confidential information that is not caused by our intentional misconduct. Thus, patients must consent to the use of e-mail for patient information. Consent to the use of e-mail includes agreement with the following conditions:

  • All e-mails to or from the patient concerning the diagnosis or treatment will be printed out and made part of the patient's medical record. Because they are part of the medical record, other individuals authorized to access the medical record, such as staff and billing personnel, will have access to those e-mails.
  • We may forward e-mails internally to our staff and agents as necessary for diagnosis, treatment, reimbursement, and other handling. We will not, however, forward e-mails to independent third parties without the patient's prior written consent, except as authorized or required by law.
  • Although we will endeavor to read and respond promptly to an e-mail from the patient, we cannot guarantee that any particular e-mail will be read and responded to within any particular period of time. Thus, the patient shall not use e-mail for medical emergencies or other time-sensitive matters.
  • If the patient's e-mail requires or invites a response from us, and the patient has not received a response within a reasonable time period, it is the patient's responsibility to follow up to determine whether the intended recipient received the email and when the recipient will respond.
  • The patient should not use e-mail for communication regarding sensitive medical information, such as information regarding sexually transmitted diseases, AIDS/HIV, mental health, developmental disability, or substance abuse.
  • The patient is responsible for informing us of any types of information the patient does not want to be sent by e-mail, in addition to those set out in the section above.
  • The patient is responsible for protecting his/her password or other means of access to e-mail. We are not liable for breaches of confidentiality caused by the patient or any third party.
  • We shall not engage in e-mail communication that is unlawful, such as unlawfully practicing medicine across state lines.
  • It is the patient's responsibility to follow up and/or schedule an appointed if warranted.

3. Instructions

To communicate by e-mail, the patient shall:

  • Limit or avoid use of his/her employer's computer.
  • Inform us of changes in his/her email address.
  • Put the patient's name in the body of the e-mail.
  • Include the category of communication in the e-mail's subject line, for routing purposes (e.g. general question).
  • Review e-mail to make sure it is clear and that all relevant information is provided before sending it to the us.
  • Inform us whether the patient received an e-mail from us.
  • Take precautions to preserve the confidentiality of e-mails, such as safeguarding his/her computer password.
  • Withdraw consent only by written communication to us.

4. Patient Acknowledgement and Agreement

I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communication of e-mail between the Provider and me, and consent to the conditions outlined herein. In addition, I agree to the instructions outlines herein, as well as any other instructions that Provider may impose to communicate with patients by e-mail. Any questions I may have had were answered.

Patient Signature: Date:
Witness Signature: Date:

This form was adapted from E-Mail Consent Form provided by Health Information Compliance Insider.
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