Email Consent Form

Patient name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

E-mail: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (please print clearly and legibly)

## 1. RISK OF USING E-MAIL

Transmitting patient information by E-mail has a number of risks that patients should consider before using E-mail. These include, but are not limited to, the following risks:

- a) The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) recommends that E-mail that contains protected health information be encrypted. E-mails sent from Dr. Treyzon and the Practice are not encrypted, Therefore it is possible that the confidentiality of such so E-mails may not be secure. communications may be breached by a third party.
- b) E-mail can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients.
- c) E-mail senders can easily misaddress an E-mail.
- d) E-mail is easier to falsify than handwritten or signed documents.
- e) Backup copies of E-mail may exist even after the sender or the recipient has deleted his or her copy.
- f) Employers and on-line services have a right to inspect E-mail transmitted through their systems.
- g) E-mail can be intercepted, altered, forwarded, or used without authorization or detection.
- h) E-mail can be used to introduce viruses into computer systems.

Practice server could go down and E-mail would not be received until the server is back on-line.

- i) E-mail can be used as evidence in court.

2. cannot guarantee but will use reasonable 2. cannot guarantee but will use reasonable CONDITIONS FOR THE USE OF E-MAIL means to maintain security and confidentiality of E-mail information sent and received. Practice and Physician are not liable for improper disclosure of confidential information that is not caused by Practice's or Physician’s intentional misconduct. Patients must acknowledge and consent to the following conditions:

- a) E-mail is not appropriate for urgent or emergency situations. Practice and Physician cannot guarantee that any particular E-mail will be read and responded to within any particular period of time.
- b) If the patient’s E-mail requires or invites a response from Practice or Physician, and the patient has not received a response within two (2) business days, 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.
- c) E-mail must be concise. The patient should schedule an appointment if the issue is too complex or sensitive to discuss via E-mail.
- d) All E-mail will usually be printed and filed in the patient's medical record.
- e) Office staff may receive and read your messages.
- f) Practice will not forward patient identifiable E-mails outside of the Practice without the patient's prior written consent, except as authorized or required by law.
- g) The patient should not use E-mail for communication regarding sensitive medical information, such as information regarding sexually transmitted diseases, AIDS/HIV, mental health, or substance abuse. Practice is not liable for breaches of confidentiality caused by the patient or any third party.
- h) It is the patient's responsibility to follow up and/or schedule an appointment if warranted.
- i) This consent will remain in effect until terminated in writing by either the patient or Practice.
- j) In the event that the patient does not comply with the conditions herein, Practice may terminate patient’s privilege to communicate by E-mail with Practice.