Office Web Site and Email Policy

If you choose to correspond with your Provider using this web site or by email, please understand that we
cannot guarantee secure electronic transmissions when using your provider’s web site, email with your
provider or email attachments.  The term “Provider” used in this consent refers to your physicians and
their staff.  

Appropriate use: Email should never be used for emergency or urgent problems.  For a life-threatening
emergency, call 911.  For non urgent or sensitive problems, call our office.  We recommend office visits
for all new, complex or sensitive problems.  When we are not in the office, the answering message will
direct you to an on-call doctor who can give advice or direct you to a source of emergency or urgent care.

Fees:  A fee is charged for filling prescriptions outside of an office visit.  Fees will not be charged when
we notify you by email of laboratory reports following an office visit, for appointment scheduling, billing
questions, or general information such as office hours, location and directions.  For other needs, please
make an office appointment.

Risks Of Using Email to Communicate With Your Provider: Transmitting patient information by e-
mail has risks that patients should consider. Risks include, but are not limited to: a. Email can be
circulated, forwarded, and stored in paper and electronic files., b. Email can be broadcast worldwide or
can be received by unintended recipients at home or at work., c. Email senders can accidentally type the
wrong email address or send to others besides the intended recipient.,  d. Email is easier to falsify than
handwritten or signed documents.,  e. Backup copies of Email may exist even after the sender or the
recipient has deleted his or her copy.,  f. Employers and on-line services may have a right to archive and
inspect Emails exchanged via their systems.,  g. Email can be used as evidence in court.,  h. Email can
introduce viruses or worms into computer systems.

Conditions For The Use Of Email

Provider will use reasonable means to protect the security and confidentiality of Email information sent
and received. However, Provider 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 Provider’s intentional misconduct. Thus, patients who consent to exchange patient information in
Email, indicate agreement with these conditions:  a. All Emails to or from the patient concerning treatment
will be added to the patient’s medical record.,  b. Other individuals authorized to access the medical
record will have access to those Emails.,  c. Provider may forward Emails internally to Provider’s staff as
necessary for treatment, payment, and operations. Provider will not forward emails to independent third
parties without the patient’s prior written consent, except as authorized or required by law or as indicated
to coordinate care (for example, sending a copy of test results or a progress note to consultants).,  d.
Provider or staff shall confirm when an Email from the patient has been received and read.  However, the
patient shall not use Email for medical emergencies, urgent problems or other time sensitive matters.,  e.
If the patient’s Email requires or requests a response from Provider, and the patient has not received a
response within 3 days, the patient is responsible to follow up to determine whether the intended recipient
received the Email and when he/she will respond.,  f. The patient 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.,  g. The patient is responsible for
informing Provider of any other types of information the patient does not want to be sent by Email.,  i.  
The patient is responsible for protecting his/her password or other means of access to Email.  Provider is
not liable for breaches of confidentiality caused by the patient or any third party.,  j. Provider shall not
engage in Email communication that is unlawful, such as unlawfully practicing medicine across state lines
or treating patients who have not first been seen in the office.,  k. It is the patient’s responsibility to follow
up and/or schedule an appointment if warranted.

Patient Responsibilities And Instructions

To communicate by Email, the patient shall:  a. Avoid use of computers the patient in not authorized to
use.,  b. Inform Provider of changes in his/her email address.,  c. Confirm that he/she has received and
read an Email from the Provider.,  d. Put the patient’s name in the body of the Email.,  e. Include the
category of the communication in the Email’s subject line, for routing purposes (e.g., billing question).,  f.
Review the Email to make sure it is clear and that all relevant information if provided before sending to
Provider.,  g. Take precautions to preserve the confidentiality of Email, such as using screen savers and
safeguarding his/her computer password.,  h. Withdraw consent only by Email or written communication to
Provider.,  i. Email should be brief, and to the point.

Alternate Forms Of Communication:  I understand that I may also communicate with the Provider via
telephone or during a scheduled appointment and that Email is not a substitute for the care that may be
provided during an office visit.  If no response from email is received after 3 days, the patient should call
the office.

Types Of Email Transmissions That Patient Agrees To Send And/Or Receive:  Types of information
that can be communicated via Email with the Provider include prescription refills, referral requests,
appointment scheduling requests, billing and insurance questions, patient education, and clinical
consultation.  If you are not sure if the issue you wish to discuss should be included in an Email, please
call Provider’s office to schedule an appointment.

Hold Harmless:  I agree to indemnify and hold harmless the Provider, its employees, agents, information
providers and suppliers, and website designers and maintainers from and against all losses, expenses,
damages and costs, including reasonable attorney’s fees, relating to or arising from any information loss
due to technical failure, my use of the internet to communicate with the Provider or to use Provider’s Web
Site, any arrangements made based on information obtained at the Site, any products or services
obtained through the Site, and any breach by me of these restrictions and conditions.  The Provider does
not warrant that the functions contained in any materials provided will be uninterrupted or error-free, that
defects will be corrected, or that the Provider’s Site or the server that makes the Site available is free of
viruses or other harmful components.

Termination Of The Email Relationship:  Provider has the right to immediately terminate the Email
relationship with a patient if he/she determines, in his/her sole discretion, that patient has violated the
terms and conditions set forth above or otherwise breached this agreement, or has engaged in conduct
which the Provider determines, in his/her sole discretion, to be unacceptable.  The Email relationship
between the Provider and the patient will terminate in the event the Provider, in his/her sole discretion, no
longer wishes to utilize the Email to communicate with all of his/her patients. Patient also has the right to
terminate the email relationship by written notice to Provider, at any time.

Patient Acknowledgement And Agreement:  As a user of the aforementioned web site and email
services, I am expected to read and fully understand this consent form and will discuss any questions with
the Provider or his/her representative. I understand the risks associated with the communication of Email
between the Provider and me, and consent to the conditions above. In addition, I agree to the instructions
described above, as well as other instructions posted at my provider’s office.