E-Mail / Text Messaging Consent

E-Mail / Text Messaging Consent
At Aspire Medical Group, we offer patients/parents/legal guardians the opportunity to communicate by e-mail or text messaging. Using e-mail to discuss patient information, however, is different than phone messaging. Text messaging is not to be used to convey medical information or to discuss medical conditions. E-mail and/or text message communication has a number of possible risks that patients/parents/legal guardians should consider before using e-mail or text messaging. If the patient/parent/legal guardian is worried about any information being seen by other people, or if the question or problem is urgent, then other form(s) of communication such as telephone communication should be used.

Possible risks of using e-mail or text messaging include, but are not limited to, the following:
- E-mail or text messages can be forwarded to other people, stored on a computer, or printed on paper.
- E-mail or text messages can be sent and received by multiple recipients, sometimes accidentally.
- E-mail or text message information can be altered more easily than handwritten or signed documents.
- E-mail or text message information may be stored on computers or devices even after being deleted.
- E-mails or text messages can be intercepted, altered, forwarded, or used without authorization or detection.
- E-mails or text messages can introduce viruses into computer systems.
- E-mails or text messages can be used as evidence in court.
Conditions for the Use of E-Mail and Text Messaging

Aspire Medical Group will use reasonable means to protect the security and confidentiality of e-mail/text message information sent and received. However, due to the risks outlined above, we cannot guarantee the security and confidentiality (privacy) of e-mail/text messaging communication and will not be liable for improper use or disclosure of confidential information, including Protected Health Information (PHI) as defined by HIPAA.

By consenting to the use of e-mail/text messaging, the patient/parent/legal guardian agrees to the following conditions:

Text messages are used by healthcare providers for appointment reminders or to share general information. When a patient/parent/legal guardian sends a text message, there should be no expectation of a response from the healthcare provider.

Healthcare providers and practices cannot engage in unlawful e-mail or text communication, such as practicing medicine across state lines.
Patient Information
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Age (years)*
Phone Number
By providing my mobile number, I am authorizing Aspire Medical Group to use my mobile number for communication, including appointment reminders and the transmission of my personal and health-related information.
Email
By providing my email address, I am authorizing Aspire Medical Group to use my email address for communication, including the transmission of my personal and health-related information.
Patient Acknowledgement and Consent
- I acknowledge that I am voluntarily signing this E-mail/Texting Consent Form.
- I acknowledge that I have both read and fully understand the information the health care provider and/or practice has provided me regarding the risks of using e-mail or text messaging.
- I understand the risks associated with the communication of e-mail or text messages between the health care provider and/or practice and me, and consent to the Conditions outlined above. In addition, I agree to the above instructions, as well as any other instructions that the health care provider and/or practice may impose regarding e-mail or text message communications.
- Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me.
- By signing this form, I agree to use electronic records and signatures and I acknowledge that I have read the related consumer disclosure.
Electronic Signatures
By providing my electronic signature below, I agree to the terms and conditions outlined in this agreement. I agree to the use of electronic records and signatures. I acknowledge that I have read the related consumer disclosure.

The parties acknowledge and agree that this financial agreement form may be executed by electronic signature, which shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature. Without limitation, “electronic signature” shall include faxed versions of an original signature or electronically scanned and transmitted versions (e.g., via PDF) of an original signature.
Patient Name*

First NameLast Name
Patient Signature*

Clear
Date of Signature*

MonthDayYear
Date
If the patient is a minor or is not legally competent to provide consent, the signature of a parent, guardian, or legal representative is required
Parent, Guardian, or Legal Representative Name

First NameLast Name
Signature of Parent, Guardian, or Legal Representative

Clear
Relationship to Patient (Parent, Guardian, or Legal Representative)
Should be Empty:

E-Mail / Text Messaging Consent

Patient Information

Patient Acknowledgement and Consent

Electronic Signatures

If the patient is a minor or is not legally competent to provide consent, the signature of a parent, guardian, or legal representative is required