E-MAIL/TEXT CONSENT FORM
Before sending e-mail/text communications to MHW Healing Arts Center Providers (“MHW”), please read and agree to the following information regarding the risks and conditions of e-mail/text use: RISKS ASSOCIATED WITH USING E-MAIL/TEXT
MHW offers patients the opportunity to communicate by e-mail/text. However, transmitting patient information by e-mail/text has a number of risks that should be considered. These include, and are not limited to, the following risks:
- E-mail/text can be circulated, forwarded, and stored in numerous paper and electronic files.
- E-mail/text can be immediately broadcast worldwide and be received by many intended and unintended recipients.
- E-mail/text senders can easily misaddress an e-mail/text.
- E-mail/text is easier to falsify than handwritten or signed documents.
- Backup copies of e-mail/text may exist even after sender or recipients have deleted their copy.
- Employers and on-line services have a right to archive and inspect e-mails/texts transmitted through their systems.
- E-mail/text can be intercepted, altered, forwarded, or used without authorization or detection.
- E-mail/text can be used as evidence in court.
CONDITIONS FOR THE USE OF E-MAIL/TEXT
MHW will use reasonable means to protect the security and confidentiality of e-mail/text information sent and received. However, because of the risks outlined above, MHW cannot guarantee the security and confidentiality of e-mail/text communication, and will not be liable for improper disclosure of confidential information that is not caused by MHW’s intentional misconduct. Thus, individuals must consent to the use of e-mail/text communication. Consent to the use of e-mail/text includes agreement with the following conditions:
- Although MHW will endeavor to read and respond properly to an e-mail/text, MHW cannot guarantee that any particular e-mail/text will be read and responded to within any particular period of time. Thus, no one shall use e-mail for medical emergencies or other time sensitive matters. Please call 911 for emergencies and go to the nearest urgent care or immediate care center for urgent matters.
- All e-mails/texts sent to providers must be sent to their respective e-mail/text addresses.
- Providers will likewise respond to all patient e-mails/texts from their respective e-mail/text address.
- All Emails/Text to or from MHW patients concerning diagnosis or treatment will be printed out and, at the Provider’s discretion, may be made a part of the patient’s medical record. Because they are a part of the medical record, other individuals authorized to access the medical records, such as a staff or billing personnel, will have access to those e-mails/texts. • MHW may forward e-mails/texts internally to the practice’s staff and agents as necessary for diagnosis, treatment, reimbursement, and other handling. MHW will not, however, forward emails/texts to independent third parties without the patient’s prior written consent, except as authorized or required by law.
- If the individual’s e-mail/text required or invites a response from MHW, and the individual has not received a response in a timely manner or within a business week, it is the individual’s MHW responsibility to follow up by telephone to determine whether the intended recipient received the e-mail/text and when the recipient will respond.
- Individuals should not use e-mail/text communication regarding sensitive medical information such as information regarding sexually transmitted diseases, AIDS/HIV, mental health, developmental disability, or substance abuse.
- Individuals are responsible for informing MHW of any types of information that they desire not to be sent by e-mail/text, in addition to those called out in the above paragraph.
- The individual is responsible for protecting his/her password or other means of access to email/text. MHW is not liable for breaches of confidentiality caused by the individual or any third party.
- MHW shall not engage in e-mail/text communication that is unlawfully practicing medicine across state lines.
- It is the individual’s responsibility to follow up and/or schedule an appointment if warranted.
COMMUNICATION BY E-MAIL/TEXT To communicate by e-mail/text, patients shall:
- Limit or avoid the use of his/her employer’s computer.
- Inform MHW of changes in his/her e-mail/text address.
- Put the patient’s name in the body of the e-mail/text.
- Review the e-mail/text to make sure it is clear and that all relevant information is provided before sending to MHW.
- Take precautions to preserve the confidentiality of e-mail/text, such as using screen savers and safeguarding his/her computer password.
- Withdraw consent only by written communication to MHW.
ACKNOWLEDGEMENT & AGREEMENT
I understand and acknowledge that I have read and fully understood this consent form. I request and consent to MHW using e-mail/text to communicate with me at the e-mail address(es)/telephone number(s) that I provide and I understand that such communications may contain my protected health information, including health history, diagnosis and treatment information and demographic information. I understand the risks associated with e-mail/text communication between MHW and me, and consent to the conditions outlined above. In addition, I agree to the instructions for communication by e-mail/text outlined here, as well as any other instructions that MHW may impose to e-mail/text communications. I understand and acknowledge that I have the right to withdraw my consent in writing at any time and that this authorization shall remain in effect until I withdraw my consent. Furthermore, I understand that MHW may not condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization.
If you wish to have secure HIPAA compliant conversations with any medical provider at MHW, then please use the secure Patient Fusion portal system: https://www.patientfusion.com