Consent to E-Mail Communications

Consent to E-Mail Communications

This form is HIPAA compliant and secure.
Are you completing this form for someone other than yourself? *

No. I am completing this for myself Yes. I am completing this form on behalf of the patient
Your Name:

First Name Last Name
Relationship to Patient:
Patient Name: *

First Name Last Name
Birth Date: *

Month Day Year
SSN: *
Do not include dashes
By signing below, I consent to e-mail correspondence between Youth Home, Inc. and the following e-mail addresses regarding the medical care of the patient listed above:
Number of emails granting consent to contact? *

1 2 3
Email 1
example@example.com
Email 2
example@example.com
Email 3
example@example.com
I affirm that I understand the following: (MUST CHECK EACH BOX) *

E-mail communications are for convenience and are not appropriate for emergency or urgent care situations. I will not use e-mail to obtain medical advice. In particular, medical complaints, diagnoses, test results, etc. will not be discussed. Youth Home staff will monitor their e-mail regularly, and I agree to monitor the above e-mail boxes regularly and respond as needed. E-mail communication based upon this authorization may or may not become part of the patient’s records at Youth Home, as determined by Youth Home. E-mail is not a totally secure and confidential means of communication. It is my responsibility to safeguard the private health information transmitted via e-mail once it has been received from Youth Home. Youth Home, Inc. is not responsible for a breach of private health information that has been transmitted via e-mail at my request. (A separate Request for Access form will be completed for records requested via e-mail.) E-mail information which I provide may be used for routine care, payment, and other business operations of Youth Home and may be shared with medical consultants as deemed necessary by Youth Home. The subject line of each e-mail I send will indicate the nature of the e-mail. I will contact Youth Home by phone if I am not getting a response from Youth Home by e-mail after an appropriate time, and I agree that the length of that time period is my judgment to make.
Signature

Clear
Should be Empty: