Email Consent

Email Consent
Patient Name*
Patient E-mail Address:*
RISK OF USING EMAIL
Coastal Fertility Medical Center (CFMC) 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:
E-mail can be circulated, forwarded, and stored in numerous paper and electronic files.
E-mail can be immediately broadcast worldwide and be received by many intended and unintended recipients.
E-mail senders can easily misaddress an email.
Email is easier to falsify than handwritten or signed documents.
Backup copies of e-mail may exist even after the sender or the recipient has deleted his or her copy.
Employers and online services have a right to archive and inspect e-mails transmitted through their systems,
E-mail can be intercepted, altered, forwarded, or used without authorization or detection.
E-mail can be used to introduce viruses into computer systems.
E-mail can be used as evidence in court
CONDITION FOR THE USE OF E-MAIL
CFMC will use reasonable means to protect the security and confidentiality of e-mail information sent and received. However, because of the risks outlined above, CFMC cannot guarantee the security and confidentiality of e-mail communication and will not e liable for improper disclosure of confidential information that is not caused by Provider’s intentional misconduct. Thus, patients must provude written consent, except as authorized or required by law.
Consent to the use of e-mail for patient information. Consent to the use of E-mail includes agreement with the following conditions:
a. 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.
b. Your Provider may forward e-mails internally to CFMC staff and agents as necessary for diagnosis, treatment, reimbursement, health care operations, and other handling .Your Provider will not, however forward e-mails to independent third parties without the patient’ s prior written Consent, except as authorized or required by law.
c. Although CFMC staff will endeavor to read and respond Promptly to an e-mail from the patient, we 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.
d. If the patients e0mail 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.
e. The patient should not use e-mail for communicationregarding sensitive medical information such as information regarding sexually transmitted diseases, AIDS/HIV, mental Health, developmental disability, substance abuse.
f. The patient is responsible for informing your provider of any type of information the patient does not want to be sent by e-mail, in addition to those set out in 2(e) above
g. The patient is responsible for protecting his/her pass word or other means of access to e-mail. CFMC is not liable for breaches of confidentiality caused by the patient or any third party.
h. CFMC Providers shall not engage in e-mail communication that is unlawful, such as unlawful practicing medicine across state lines.
i. It is the patient’s responsibility to follow up and/or schedule an appointment if warranted.
INSTRUCTIONS
To communicate by e-mail, the patient shall:
a. Limit or avoid se of his/her employer’s computer.
b. Inform CFMC of changes in his/her e-mail address.
c. Put the patient’s name in the body if the e-mail.
d. Include the category of the communication in the e.mail’s subject line, for routing purposes (e.g., billing question).
e. Review the e-mail to make sure it is clear and that all relevant information is provided before sending to your Provider.
f. Inform your Provider that the patient received an email from your Provider.
g. Take precautions to preserve the confidentiality of e-mails, such as using screen savers and safeguarding his/her computer password.
h. Withdraw consent only by e-mail or written communication to your Provider.
PATIENT ACKNOWLEDGMENT 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 CFMC staff and me, and consent to the conditions 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*
Witness signature*
Date(Patient)*

MM slash DD slash YYYY
Date(Witness)*

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Phone

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