Herbal Care Rx Email Consent Form

Patient Name*

Patient Email*

example@example.com

I am:

The patient, and I need these forms emailed to myself.The patient, authorizing my personal medical information to be released to a third-party via email or secure electronic upload.An adult caregiver or guardian completing this form on behalf of a minor or patient under my guardianship.

Your name (as caregiver/guardian):

What is the name of the person/entity you are authorizing release of your health records to? Please also provide the email or secure electronic upload link for forwarding health documents to that person/entity.

By signing this form, I certify that:

•I have read or had this form explained to me.

•I fully understand its contents including the risks and benefits of the Telehealth appointment/consultation.

•I have been given ample opportunity to ask questions and that all questions have been answered to my satisfaction.

Risks of using Email:

Transmitting patient information via email has possible risks that patients should consider. These include but are not limited to, the following:

•Email can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients.

•Most popular email services (ex. Hotmail®, Gmail®, Yahoo®) do not utilize encrypted email.

•Email senders can easily misaddress an email.

•Backup copies of email may exist even after the sender of the recipient has deleted his or her copy.

•Employers and on-line services have a right to inspect email transmitted through their systems.

•Email can be intercepted, altered, forwarded or used without authorization or detection.

•Email can be used to introduce viruses into computer systems.

•You should carefully consider the use of e-mail for the communication of sensitive medical information such as but not limited to; information regarding sexually transmitted diseases, AIDS/HIV, mental health, developmental disability, or substance abuse.

The patient and clinician must consent to the following conditions:

•Email communications between patient and clinician will be filed in the patient’s record.

•The patient’s messages may also be delegated to another clinician or staff member for response.

•The clinician cannot guarantee but will use reasonable means to maintain security and confidentiality of email information sent and received.

•Data stored in Herbal Care Rx's electronic records are encrypted. Records of email communication between patients and Herbal Care Rx are retained in this manner.

•The clinician will not forward patient-identifiable emails outside of Herbal Care Rx without the patient’s prior written consent, except as authorized or required by law.

• I acknowledge that I have read and fully understand this consent form. I understand the possible risks associated with the communication of email between Herbal Care Rx and myself, as well as any third party entities I have authorized release of health information to. I consent to the conditions and instructions outlined here. I agree to use the pre-designated email address specified above. Any questions I may have had were answered.

Today's Date*

Date

Please Enter Patient's Date of Birth Below*

ex. 02-15-1980

Your Signature*