Electronic Mail Consent

Before allowing electronic mail (“email”) communications with Pine Street Clinic LLC, please read and agree to the following information regarding the risks and conditions of email use:

The Risks of Using Electronic Mail

We offer patients and other individuals the opportunity to communicate by email. However, transmitting patient information by email has a number of risks that should be considered. These include, and are not limited to, the following risks:

• Email can be circulated, forwarded, and stored in numerous paper and electronic files.
• Email can be immediately broadcast worldwide and be received by many intended and unintended recipients.
• Email senders can easily misaddress an email.
• Email is easier to falsify than handwritten or signed documents.
• Backup copies of email may exist even after sender or recipients have deleted their copy.
• Employers and on-line services have a right to archive and inspect emails transmitted through their systems.
• Email can be intercepted, altered, forwarded, or used without authorization or detection.
• Email can be used as evidence in court.

Conditions for the Use of Electronic Mail

We will use reasonable and appropriate means to protect the security and confidentiality of email information sent and received. However, because of the risks outlined above, we cannot guarantee the security and confidentiality of email communication, and will not be liable for improper disclosure of confidential information that is not caused by our intentional misconduct. Thus, individuals must consent to the use of email for information. Consent to the use of email includes agreement with the following conditions:

1. All emails to or from patients concerning diagnosis or treatment may be printed out and made part of patient's medical record. Because they are part of the medical record, other individuals authorized to access the medical record, such as staff and billing personnel, will have access to those emails.
2. We may forward emails internally to the practice's staff and agents as necessary for diagnosis, treatment, reimbursement, and other handling. We will not, however, forward emails to independent third parties without the patient's prior written consent, except as authorized or required by law.
3. Although we will endeavor to read and respond promptly to an email, we cannot guarantee that any particular email will be read and responded to within any particular period of time. Thus, patients should use email for medical emergencies or other time-sensitive matters.
4. If the individual's email requires or invites a response, and the individual has not received a response within a reasonable time period, it is the individual's responsibility to follow up to determine whether the intended recipient received the email and when the recipient will respond.
5. Individuals should not use email for communication regarding sensitive medical information such as information regarding sexually transmitted diseases, AIDS/HIV, mental health, developmental disability, or substance abuse.
6. Individuals are responsible for informing us of any types of information that they desire not to be sent by email, in addition to those out in the above paragraph.
7. The individual is responsible for protecting his/her password or other means of access to email. We are not liable for breaches of confidentiality caused by the individual or any third party.
8. We will not engage in email communication that is unlawful, such as unlawfully practicing medicine across state lines.
9. It is the individual's responsibility to follow up and/or schedule an appointment if warranted.

Communicating by email

To communicate by email, patients and other individuals shall:

1. Limit or avoid the use of his/her employer's computer.
2. Inform us of changes in his/her email address.
3. If the sender is a patient of ours, to put the patient's name in the body of the email.
4. Review the email to make sure that it is clear and that all relevant information is provided before sending.
5. Take precautions to preserve the confidentiality of email, such as using screen savers and safeguarding his/her computer password.
6. Withdraw consent only by email or written communication to the practice.

Acknowledgment and Agreement

I acknowledge that I have read and fully understood this consent form. I understand the risks associated with the communication of email between Pine Street Clinic LLC and me, and consent to the conditions outlines herein. In addition, I agree to the instructions for communicating by email outlined herein, as well as any other instructions that Pine Street Clinic LLC may impose to communicate using email.

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