Re: email consent [2 Attachments]

[Guest guest]

Thank you so much!!

dannielle

To: Sent: Tue, April 3, 2012 9:14:31 AMSubject: Re: email consent [2 Attachments]

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