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