CONSENT TO COMMUNICATE PHI BY EMAIL
I expressly permit ImmediaDent (IMD) to communicate my Protected Health Information (PHI) via email to the email address indicated on my patient registration form, patient record, or this form. This permit also applies to any email
that IMD may send to my referring dental/medical provider, if appropriate.
E-MAIL RISKS AND YOUR RESPONSIBILITY
If you agree to permit IMD to use e-mail to communicate with you, you should be aware of the following risks and/or your responsibilities:
As the Internet is not secure or private, unauthorized people may be able to intercept, read, and possibly modify the email you send or are sent by IMD.
ACKNOWLEDGMENT AND AGREEMENT
ImmediaDent will use reasonable means to protect the privacy of the patient’s health information. However, because of the risks outlined above, we cannot guarantee that e-mail will be confidential. Additionally, IMD will not be liable in the event that you or anyone else inappropriately uses or accesses your e-mail.
By signing below, I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communications of e-mail between IMD and me, and consent to the conditions outlined. Any questions I may have had were answered. I understand that this consent is valid until such time as I revoke the consent in writing to ImmediaDent.