email consent

[Guest guest]

Does anyone have an "email consent" form for patients that they would like to share??Thank you!Dannielle Harwood, MD

[Guest guest]

Below is what I use for email consent. No one seems to have a problem with it. I plan to add an extension to cover use of phones since many phone calls are now completed via non secure internet resources beyond my control. In three years, no one has expressed concern about the form. No doubt a good legal team could make it three times as long and twice as boring. Given that no phone company, cable company or ISP is likely to ever sign a Business Associates Agreement, I’m inclined to believe that being upfront about my inability to assure communications security via phone and internet it the best policy. In time, patients may use secure portals more frequently but for now most see passwords and user names as a nuisance. The Facebook generation seems more about ease of access over privacy with the desire for instant information relentlessly gaining ground over privacy concerns. Suggestions for improving the disclaimer below are appreciated. Having not made any changes in three years I have likely missed newer ways phone systems and internet can misbehave. To accommodate patients I use text messages, Text-To Speech voice calls and Email as preferred by patients. Patients also receive automated appointment and IMH reminders by all three mediums. A new application I’m testing makes all three work together seamlessly with my EMR. I do not use email for issues that can be discussed at an appointment or that involve sensitive information unless requested by the patient. Neighbors, MDHuntsville, Alabama Solo using FlexMedical EMR/Billing since 2/2009Attested MU in 2011 Office Web Site and Email PolicyIf you choose to correspond with your Provider using this web site or by email, please understand that we cannot guarantee secure electronic transmissions when using your provider’s web site, email with your provider or email attachments. The term “Provider” used in this consent refers to your physicians and their staff. Appropriate use: Email should never be used for emergency or urgent problems. For a life-threatening emergency, call 911. For non urgent or sensitive problems, call our office. We recommend office visits for all new, complex or sensitive problems. When we are not in the office, the answering message will direct you to an on-call doctor who can give advice or direct you to a source of emergency or urgent care.Fees: A fees is charged for filling prescriptions outside of an office visit. Fees will not be charged when we notify you by email of laboratory reports following an office visit, for appointment scheduling, billing questions, or general information such as office hours, location and directions. For other needs, please make an office appointment.Risks Of Using Email to Communicate With Your Provider: Transmitting patient information by e-mail has risks that patients should consider. Risks include, but are not limited to: a. Email can be circulated, forwarded, and stored in paper and electronic files., b. Email can be broadcast worldwide or can be received by unintended recipients at home or at work., c. Email senders can accidentally type the wrong email address or send to others besides the intended recipient., d. Email is easier to falsify than handwritten or signed documents., e. Backup copies of Email may exist even after the sender or the recipient has deleted his or her copy., f. Employers and on-line services may have a right to archive and inspect Emails exchanged via their systems., g. Email can be used as evidence in court., h. Email can introduce viruses or worms into computer systems.Conditions For The Use Of EmailProvider will use reasonable means to protect the security and confidentiality of Email information sent and received. However, Provider cannot guarantee the security and confidentiality of Email communication, and will not be liable for improper disclosure of confidential information that is not caused by Provider’s intentional misconduct. Thus, patients who consent to exchange patient information in Email, indicate agreement with these conditions: a. All Emails to or from the patient concerning treatment will be added to the patient’s medical record., b. Other individuals authorized to access the medical record will have access to those Emails., c. Provider may forward Emails internally to Provider’s staff as necessary for treatment, payment, and operations. Provider will not forward emails to independent third parties without the patient’s prior written consent, except as authorized or required by law or as indicated to coordinate care (for example, sending a copy of test results or a progress note to consultants)., d. Provider or staff shall confirm when an Email from the patient has been received and read. However, the patient shall not use Email for medical emergencies, urgent problems or other time sensitive matters., e. If the patient’s Email requires or requests a response from Provider, and the patient has not received a response within 3 days, the patient is responsible to follow up to determine whether the intended recipient received the Email and when he/she will respond., f. The patient should not use Email for communication regarding sensitive medical information, such as information regarding sexually transmitted diseases, AIDS/HIV, mental health, developmental disability, or substance abuse., g. The patient is responsible for informing Provider of any other types of information the patient does not want to be sent by Email., i. The patient is responsible for protecting his/her password or other means of access to Email. Provider is not liable for breaches of confidentiality caused by the patient or any third party., j. Provider shall not engage in Email communication that is unlawful, such as unlawfully practicing medicine across state lines or treating patients who have not first been seen in the office., k. It is the patient’s responsibility to follow up and/or schedule an appointment if warranted.Patient Responsibilities And InstructionsTo communicate by Email, the patient shall: a. Avoid use of computers the patient in not authorized to use., b. Inform Provider of changes in his/her email address., c. Confirm that he/she has received and read an Email from the Provider., d. Put the patient’s name in the body of the Email., e. Include the category of the communication in the Email’s subject line, for routing purposes (e.g., billing question)., f. Review the Email to make sure it is clear and that all relevant information if provided before sending to Provider., g. Take precautions to preserve the confidentiality of Email, such as using screen savers and safeguarding his/her computer password., h. Withdraw consent only by Email or written communication to Provider., i. Email should be brief, and to the point.Alternate Forms Of Communication: I understand that I may also communicate with the Provider via telephone or during a scheduled appointment and that Email is not a substitute for the care that may be provided during an office visit. If no response from email is received after 3 days, the patient should call the office.Types Of Email Transmissions That Patient Agrees To Send And/Or Receive: Types of information that can be communicated via Email with the Provider include prescription refills, referral requests, appointment scheduling requests, billing and insurance questions, patient education, and clinical consultation. If you are not sure if the issue you wish to discuss should be included in an Email, please call Provider’s office to schedule an appointment.Hold Harmless: I agree to indemnify and hold harmless the Provider, its employees, agents, information providers and suppliers, and website designers and maintainers from and against all losses, expenses, damages and costs, including reasonable attorney’s fees, relating to or arising from any information loss due to technical failure, my use of the internet to communicate with the Provider or to use Provider’s Web Site, any arrangements made based on information obtained at the Site, any products or services obtained through the Site, and any breach by me of these restrictions and conditions. The Provider does not warrant that the functions contained in any materials provided will be uninterrupted or error-free, that defects will be corrected, or that the Provider’s Site or the server that makes the Site available is free of viruses or other harmful components.Termination Of The Email Relationship: Provider has the right to immediately terminate the Email relationship with a patient if he/she determines, in his/her sole discretion, that patient has violated the terms and conditions set forth above or otherwise breached this agreement, or has engaged in conduct which the Provider determines, in his/her sole discretion, to be unacceptable. The Email relationship between the Provider and the patient will terminate in the event the Provider, in his/her sole discretion, no longer wishes to utilize the Email to communicate with all of his/her patients. Patient also has the right to terminate the email relationship by written notice to Provider, at any time.Patient Acknowledgement And Agreement: As a user of the aforementioned web site and email services, I am expected to read and fully understand this consent form and will discuss any questions with the Provider or his/her representative. I understand the risks associated with the communication of Email between the Provider and me, and consent to the conditions above. In addition, I agree to the instructions described above, as well as other instructions posted at my provider’s office. From: [mailto: ] On Behalf Of Dannielle HarwoodSent: Monday, April 02, 2012 10:39 PMTo: Subject: email consent Does anyone have an " email consent " form for patients that they would like to share??Thank you!Dannielle Harwood, MD

[Guest guest]

le,Here is the e-mail consent form that I have been using in my practice. Feel free to use and modify however you would like. SetoSouth Pasadena, CAE-mail Consent FormWhat should I know about e-mail communication?

E-mail is fast, convenient, and efficient. E-mail works well for many non-urgent

questions, requests or messages you may have for your doctor. The most important thing

you should know is that the confidentiality of e-mail exchanges cannot be guaranteed.

While the security of e-mail is comparable to other types of communication (such as

phone calls), there are some special issues with e-mail:

If your e-mail address is through your employer, your employer may own all e-mails

sent to that address.

If your e-mail address is a family address, other family members may see your

messages.

If you use an internet service provider, there is a small risk that messages may be

intercepted by others (“hackers”).

You should also know that e-mail you send to your doctor may be read by others in

the practice. For the present time, Dr. Seto does not have any office staff who

have access to his e-mail, but may hire employees in the future who may have this

access.

What types of communication are appropriate for e-mail?

Prescription refill requests

Appointment scheduling (You can also book your own appointments online) Non-urgent medical advice or follow-up (including some types of test results) Billing/insurance questions

The following subjects are never appropriate for e-mail:

Any urgent medical problem or emergency Mental health issues

Drug and alcohol problems

HIV and other sexually transmitted diseases

Please keep in mind that although e-mail can be a very effective tool, it is not a substitute

for a physical exam or counseling by your doctor.

How much does it cost to communicate with Dr. Seto by e-mail?

There is no charge for most e-mail messages. However for frequent or lengthy e-mail

messages or those dealing with a new medical problem, the fee for e-mail messages is

$30 per message.

What if I do not want to communicate by e-mail?

You do not need to complete this form. You may still communicate with Dr. Seto by

telephone, regular mail and in person.How do I communicate with Dr. Seto via e-mail?

To communicate with Dr. Seto and South Pasadena Family Medicine via e-mail,

simply send your e-mail to drseto@....

You can expect a response to your e-mail question or message usually within 24 hours.

On weekends or holidays or if Dr. Seto is away on vacation, then it may take up to 48

hours for a response. If you do not get an e-mail reply within the expected time, you

should assume that your e-mail was not received. You should then call the office with

your question or request.

Is there a way to send confidential messages to my doctor?

Yes. You can send a secure and confidential electronic message to Dr. Seto and

South Pasadena Family Medicine by visiting http://www.drgaryseto.com and registering

using the provided links. This is more secure and private than regular e-mail.

I have read the information above about e-mail procedures and privacy and have

received answers to all of my questions about using e-mail to communicate with

South Pasadena Family Practice Medicine.

I understand that any e-mail that I send may be seen by people other than my

doctor and that the Internet is not an error-free network. I understand that e-mail is

never appropriate for urgent or emergency situations, or sensitive subjects.

I understand the terms outlined in this notice, and I consent to the use of

unsecured e-mail in addition to other methods of communication with South

Pasadena Family Medicine.

It is my responsibility to notify Dr. Seto and South Pasadena Family Medicine in

writing if my e-mail address changes.

I understand that either I or my doctor may choose to discontinue the use of e-

mail communication at any time.

Patient Name:_______________________________________________________ Signature:__________________________________________________________ E-mail Address:_____________________________________________________ Date:_______________________

Does anyone have an "email consent" form for patients that they would like to share??Thank you!Dannielle Harwood, MD

[Guest guest]

This is what I use:

Consent to Communicate

via Non-Secure or Potentially Non-Secure Modalities

 

Patient

Name:_____________________________________________________Date:____________

 

At Healing

Path Intgrative Medicine (HPIM), we interact with the patients and their family

members for many reasons. Due to HIPAA regulations, we must have written

permission to leave messages on answering machines, voicemail or non-secure email,

or to discuss your health with family members.

This form

will be kept in your medical records for future reference. Please indicate your consent below by initialing beside each statement.

_______   I give my permission for HPIM to leave

appointment reminder messages on my voicemail, answering machine or email even

if it is not a secure portal.

_______  I give my permission for HPIM to leave

appointment reminder with any individual who answers the phone at my house.

_______  I give my permission for HPIM to leave a

message regarding my labwork on my voicemail, answering machine, fax or email

even if it is not a secure portal.

_______  I give my permission for HPIM to leave a

message regarding my labwork with any individual who answers the phone at my

house.

_______  I give my permission for HPIM to answer my

medical questions on my voicemail, answering machine, fax or email even if it

is not a secure portal.

 

 

Signature

of Patient/Legal Representative                                                                 

Date

 

 

Healing Path Integrative Medicine, PLLC – 129 Biltmore

Avenue, Asheville NC, 28801 – www.hpimed.com-  P:

 

Does anyone have an " email consent " form  for patients that they would like to share??Thank you!Dannielle Harwood, MD

-- Anne Walch, MHS, PA-CHealing Path Integrative Medicinewww.hpimed.com

[Guest guest]

I have a note about e-mail in my office policies and then on my consent form I have a specific line that states patient have read my office policies including the section on e-mail.  Both my consent and office policies are attached.  I think I pretty much stole them from when I made them.

 

This is what I use:

Consent to Communicate

via Non-Secure or Potentially Non-Secure Modalities

 

Patient

Name:_____________________________________________________Date:____________

 

At Healing

Path Intgrative Medicine (HPIM), we interact with the patients and their family

members for many reasons. Due to HIPAA regulations, we must have written

permission to leave messages on answering machines, voicemail or non-secure email,

or to discuss your health with family members.

This form

will be kept in your medical records for future reference. Please indicate your consent below by initialing beside each statement.

_______   I give my permission for HPIM to leave

appointment reminder messages on my voicemail, answering machine or email even

if it is not a secure portal.

_______  I give my permission for HPIM to leave

appointment reminder with any individual who answers the phone at my house.

_______  I give my permission for HPIM to leave a

message regarding my labwork on my voicemail, answering machine, fax or email

even if it is not a secure portal.

_______  I give my permission for HPIM to leave a

message regarding my labwork with any individual who answers the phone at my

house.

_______  I give my permission for HPIM to answer my

medical questions on my voicemail, answering machine, fax or email even if it

is not a secure portal.

 

 

Signature

of Patient/Legal Representative                                                                 

Date

 

 

Healing Path Integrative Medicine, PLLC – 129 Biltmore

Avenue, Asheville NC, 28801 – www.hpimed.com-  P:

 

Does anyone have an " email consent " form  for patients that they would like to share??Thank you!Dannielle Harwood, MD

-- Anne Walch, MHS, PA-CHealing Path Integrative Medicinewww.hpimed.com

2 of 2 File(s)

GordonConsent2012.pdf

GordonOfficePolicy2011.pdf

[Guest guest]

This is great! Thank you so much!DannielleTo: Sent: Tue, April 3, 2012 8:39:36 AMSubject: Re: email consent

This is what I use:

Consent to Communicate

via Non-Secure or Potentially Non-Secure Modalities

Patient

Name:_____________________________________________________Date:____________

At Healing

Path Intgrative Medicine (HPIM), we interact with the patients and their family

members for many reasons. Due to HIPAA regulations, we must have written

permission to leave messages on answering machines, voicemail or non-secure email,

or to discuss your health with family members.

This form

will be kept in your medical records for future reference. Please indicate your consent below by initialing beside each statement.

_______ I give my permission for HPIM to leave

appointment reminder messages on my voicemail, answering machine or email even

if it is not a secure portal.

_______ I give my permission for HPIM to leave

appointment reminder with any individual who answers the phone at my house.

_______ I give my permission for HPIM to leave a

message regarding my labwork on my voicemail, answering machine, fax or email

even if it is not a secure portal.

_______ I give my permission for HPIM to leave a

message regarding my labwork with any individual who answers the phone at my

house.

_______ I give my permission for HPIM to answer my

medical questions on my voicemail, answering machine, fax or email even if it

is not a secure portal.

Signature

of Patient/Legal Representative

Date

Healing Path Integrative Medicine, PLLC – 129 Biltmore

Avenue, Asheville NC, 28801 – www.hpimed.com- P:

Does anyone have an "email consent" form for patients that they would like to share??Thank you!Dannielle Harwood, MD

-- Anne Walch, MHS, PA-CHealing Path Integrative Medicinewww.hpimed.com