Email Informed Consent Form
Introduction
Japanese Medical Care, PLLC (“JMC”) provides patients the opportunity to communicate with
their physicians, other health care providers, and administrative services by email. Transmitting
confidential patient information by email, however, has a number of risks, both general andspecific, that patients should consider before using email.
Risk Factors
Among general email risks are the following:o Email can be immediately broadcast worldwide and be received by many intended andunintended recipients.
o Recipients can forward email messages to other recipients without the original sender’spermission or knowledge.
o Users can easily misaddress an email.
o Email is easier to falsify than handwritten or signed documents.
o Backup copies of email may exist even after the sender or the recipient has deleted his or
her copy.

Among specific patient email risks are the following:o Email containing information pertaining to a patient’s diagnosis and/or treatment must beincluded in the patient’s medical records. Thus, all individuals who have access to themedical record will have access to the email messages.
o Employees do not have an expectation of privacy in email that they send or receive attheir place of employment. Thus, patients who send or receive email from their place ofemployment risk having their employer read their email.
o If employers or others, such as insurance companies, read an employee’s email and learnof medical treatment, particularly mental health, sexually transmitted diseases, or alcoholand drug abuse information, they may discriminate against the employee/patient. Forexample, they may fire the employee, not promote the employee, deny insurance
coverage, and the like. In addition, the employee could suffer social stigma from thedisclosure of such information.
o Patients have no way of anticipating how soon JMC and its employees and agent will
respond to a particular email message. Although JMC and its employees and agents will
endeavor to read and respond to email promptly, JMC cannot guarantee that any
particular email message will be read and responded to within any particular period oftime. Physicians, nurses, and other health care workers rarely have time during rounds,surgery, consultations, appointments, staff meetings, meetings away from the facility, andmeetings with patients and their families to continually monitor whether they havereceived email. Thus, patients should not use email in a medical emergency.

Conditions for the Use of Email

It is the policy of JMC that JMC will make all email messages sent or received that concern
the diagnosis or treatment of a patient part of that patient’s medical record and will treat such
email messages with the same degree of confidentiality as afforded other portions of themedical record. JMC will use reasonable means to protect the security and confidentiality ofemail information. Because of the risks outlined above, JMC cannot, however, guarantee thesecurity and confidentiality of email communication.
315 Madison Ave, Fl 17
New York, NY 10017
Phone: 212-365-5066 Fax: 212-808-5510

3010 Westchester Ave, Ste 401
Purchase, NY 10577
Phone: 914-305-8630 Fax: 914-701-0010

Thus, patients must consent to the use of email for confidential medical information afterhaving been informed of the above risks. Consent to the use of email includes agreement withthe following conditions:o All emails to or from the patient concerning diagnosis and/or treatment will be made apart of the patient’s medical record. As a part of the medical record, other individuals,
such as other physicians, nurses, physical therapists, patient accounts personnel, and thelike, and other entities, such as other health care providers and insurers, will have accessto email messages contained in medical records.
o JMC may forward email messages within the facility as necessary for diagnosis,treatment, and reimbursement. JMC will not, however, forward the email outside thefacility without the consent of the patient or as required by law.
o If the patient sends an email to JMC, one of its physicians, another health care provider,or an administrative department, JMC will endeavor to read the email promptly and torespond promptly, if warranted. However, JMC can provide no assurance that therecipient of a particular email will read the email message promptly. Because JMC
cannot assure patients that recipients will read email messages promptly, patients
must not use email in a medical emergency.
o If a patient’s email requires or invites a response, and the recipient does not respondwithin a reasonable time, the patient is responsible for following up to determine whether
the intended recipient received the email and when the recipient will respond.
o Because some medical information is so sensitive that unauthorized disclosure can bevery damaging, patients should not use email for communications concerning
diagnosis or treatment of AIDS/HIV infection; other sexually transmissible orcommunicable diseases, such as syphilis, gonorrhea, herpes, and the like; mental
health or developmental disability; or alcohol and drug abuse.
o Because employees do not have a right of privacy in their employer’s email system,
patients should not use their employer’s email system to transmit or receive confidential
medical information.
o JMC cannot guarantee that electronic communications will be private. JMC will takereasonable steps to protect the confidentiality of patient email, but JMC is not liable for
improper disclosure of confidential information not caused by JMC’s gross negligence orwanton misconduct.
o If the patient consents to the use of email, the patient is responsible for informing JMC of
any types of information that the patient does not want to be sent by email other thanthose set out above.
o Patient is responsible for protecting patient’s password or other means of access to email
sent or received from JMC to protect confidentiality. JMC is not liable for breaches ofconfidentiality caused by patient.
o Any further use of email by the patient that discusses diagnosis or treatment by thepatient constitutes informed consent to the foregoing. You may withdraw consent tothe use of email at any time by email or written communication to JMC, attention:
Privacy and Security Officer.

I have read the above risk factors and conditions for the use of email, and I hereby consent to theuse of email for communications to and from JMC regarding my medical treatment.
___________________________________________
Signature of Patient______________________________
Date of Signature___________________________________________
Printed Name of Patient
315 Madison Ave, Fl 17
New York, NY 10017
Phone: 212-365-5066 Fax: 212-808-5510

3010 Westchester Ave, Ste 401
Purchase, NY 10577
Phone: 914-305-8630 Fax: 914-701-0010