E-MAIL
CONSENT FORM
Patient name
Patient address
Patient e-mail address
A. RISK OF
USING E-MAIL
Provider 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:
1. E-mail can
be circulated, forwarded, and stored in numerous paper and electronic flies.
2. E-mail can
be immediately broadcast worldwide and be received by many intended and
unintended.
3. E-mail
senders can easily misaddress an e-mail.
4. E-mail is
easier to falsify than handwritten or signed documents
5. Backup
copies of e-mail may exist even after the sender or the recipient has deleted
his or her copy.
6. Employers
and on-line services have a right to archive and inspect e-mails transmitted
through their systems.
7. E-mail can
be intercepted, altered, forwarded, or used without authorization or detection.
8. E-mail can
be used to introduce viruses into computer systems.
9. E-mail can
be used as evidence in court.
B. CONDITIONS
FOR THE USE OF E-MAIL
1. Provider
will use reasonable means to protect the security and confidentiality of e-mail
information sent and received. However, because of the risks outlined above,
Provider 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 Provider’s 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:
2. All
e-mails to or from the patient concerning diagnosis or treatment will be
printed out and made part of the patient’s medical record. Because they are a
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.
3. Provider
may forward e-mails internally to Provider’s staff and agents as necessary for
diagnosis, treatment, reimbursement, and other handling. Provider will not,
however, forward s-mails to independent third parties without the patient’s
prior written consent, except as authorized or required by law.
4. Although
Provider will endeavor to read and respond promptly to an e-mail from the
patient, Provider 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.
5. If the
patient’s e-mail requires or invites a response from Provider, 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 e-mail and when the recipient will respond.
6. 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.
7. The
patient is responsible for informing Provider of any types of information the
patient doss not want to be sent by e-mail, in addition to those set out In
2(e) above.
8. The
patient is responsible for protecting his/her password or other means of
access to e-mail. Provider is not liable for breaches of confidentiality caused
by the patient or any third party.
9. Provider
shall not engage in e-mail communication that is unlawful, such as unlawfully
practicing medicine across state lines.
10. It is the
patient’s responsibility to follow up and/or schedule an appointment if
warranted.
C. INSTRUCTIONS
To communicate by e-mail, the patient shall:
1. Limit or
avoid use of his/her employer’s computer.
2. Inform Provider
of changes in his/her s-mail address.
3. Put the
patient’s name in the body of the s-mail.
4. Include
the category of the communication in the e-mail’s subject line, for routing
purposes (e.g., billing question).
5. Review the
e-mail to make sure it is clear and that all relevant information is provided
before sending to Provider.
6. Inform
Provider that the patient received an e-mail from Provider.
7. Take
precautions to preserve the confidentiality of e-mails, such as using screen
savers and safeguarding his/her computer password.
8. Withdraw
consent only by e-mail or written communication to Provider.
D. 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
Provider and me, and consent to the conditions outlined herein. In addition, I
agree to the instructions outlined 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