Helping people gain better

control of their health

Email Consent Form

Many patients prefer the convenience of e-mail to other forms of communication. Texas Diabetes & Endocrinology (“the practice”) offers patients the opportunity to communicate by e-mail in certain cases. Although the practice acknowledges the conveniences of e-mail, transmitting patient information by e-mail has a number of risks that you should seriously consider prior to using e-mail. These risks include, but are not limited to, the following:

  • E-mail can be circulated, forwarded, and stored in numerous paper and electronic files.
  • E-mail can be received by many intended and unintended recipients.
  • E-mail senders can easily send an e-mail to the wrong address.
  • E-mail is easier to falsify than handwritten or signed documents.
  • E-mail can be intercepted, altered, forwarded, or used without authorization or detection.
  • E-mail can be used to introduce viruses into computer systems.
  • E-mail can be used as evidence in court.
  • Backup copies of e-mail may exist even after the sender or the recipient has deleted his/her copy.
  • Employers and on-line services have a right to archive and inspect e-mails transmitted through their systems.

Taking into account these risks, the practice will use reasonable means to protect the security and confidentiality of e-mail communications as required by HIPAA, HITECH and Texas Law. However, it is impossible for the practice to guarantee the security and confidentiality of e-mail communications. Should confidential information be improperly disclosed, through no fault of the practice, the practice will not be liable for such disclosures.

E-MAIL SHOULD NOT BE USED FOR MEDICAL EMERGENCIES.

The practice will make every effort to read and respond to an e-mail from you. The practice cannot guarantee that any particular e-mail will be read and responded to within any particular period of time. Therefore, should you need immediate assistance, please call our office directly.
By consenting to communicate with the practice through e-mail, you also agree to the following responsibilities:

  • If you send an e-mail to the practice that requires a response and one is not given within a reasonable time frame, it is your responsibility to follow up with the practice.
  • You should NOT use e-mail in order to make disclosures about sensitive medical information such as:
    1. Substance Abuse
    2. Mental Health
    3. AIDS/HIV
  • It is your responsibility to inform the practice of any changes to your e-mail address.

PATIENT ACKNOWLEDGEMENT AND AGREEMENT

I acknowledge that I have read and fully understand this consent form.
I understand the risks associated with the communication of e-mail as set forth in this consent form.
Despite the risks associated with e-mail, I agree that the practice may use e-mail to facilitate communications to or about me. I understand that disclosures regarding my treatment and diagnosis may be made to not only me, but also internally within the practice or to appropriate parties.

Email Consent Form

  • I acknowledge that I have read and fully understand this consent form.

    I understand the risks associated with the communication of e-mail as set forth in this consent form.

    Despite the risks associated with e-mail, I agree that the practice may use e-mail to facilitate communications to or about me. I understand that disclosures regarding my treatment and diagnosis may be made to not only me, but also internally within the practice or to appropriate parties.

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