Email Communication Consent Form

Email Communication Consent Form

Email Consent Form

Risks of using Email

For the ease of our patients, our office would like to offer the opportunity to communicate by email. Transmitting patient information poses several risks and the patient should not agree to communicate with the provider or staff from the clinic via
email without understanding and accepting these risks.

The risks include, but are not limited to, the following:

  • The privacy and security of email communication cannot be guaranteed.
  • Email senders can misaddress, resulting in it being sent to many unintended recipients.
  • Employers/online services may have a legal right to inspect and keep emails that
    pass through their system.
  • Even after the deletion of the email, back-up copies may exist on a computer.
  • Email is easier to falsify than signed hard copies. In addition, it is impossible to verify the true identity of the sender, or to ensure that only the recipient can read the email.
  • Emails can introduce viruses, generally damage, or disrupt the computer.
  • Email can be used as evidence in court.
  • Conditions of using Email

    Our office will use reasonable means to protect the security and confidentiality of email information sent and received—however, we cannot guarantee the security of email communication. Thus, patients must consent to the use of email for patient information, billing, and communication. Consent to use email includes agreement with the following conditions:

  • Emails to or from the patient concerning treatment may be printed in full and made part of the patient’s medical record. Because they are part of the medical record, authorized individuals will have access to the medical record/email (e.g. billing staff).
  • Our office may forward emails internally to those involved, as necessary, for healthcare operations and other handling. Our staff will not forward emails to independent third parties without the patient’s prior written consent, except as authorized or required by law.
  • Although our office will endeavor to read and respond promptly to all emails from the patient, it is not guarantee that any particular email will be read and responded to within any particular period of time. The patient should not use email for medical/mental health emergencies or other time sensitive matters.
  • If the patient’s email invites a response from the clinic staff and a response is not received within a reasonable time period, it is the patient’s responsibility to follow-up.
  • Please detail any information that the patient would not like to be communicated over email:
  • The patient can add to or modify this list at any time by notifying the office in writing.

    Instructions for communication by Email

    To communicate by email, the patient shall:

  • Limit or avoid using an employer’s or other third party’s computer.
  • Inform the office of any changes in the patient’s email address.
  • Take precautions to preserve the confidentiality of emails, such as using screen savers and safeguarding computer passwords.
  • Should the patient require immediate assistance or has serious or worsening condition, the patient should not rely on email. Instead, the patient should call the office for an appointment or take other measures as appropriate.
  • Patient acknowledgement and agreement

    I acknowledge that I have read and fully understand this consent form. I understand the risks associated with communication of email between the office and me, and consent to the conditions outlined herein, as well as any other instructions that the office may impose to communicate with patients by email. I acknowledge the office’s right to, upon the provision of written notice, withdraw the option of communication through email.

    Any questions I may have had were answered.

    Start Over
    Scroll to Top