Email Informed Consent Form

Introduction

Aces Physical Therapy provides patients the opportunity to communicate with Aces Physical Therapy and its employees or agents by email. Transmitting confidential patient information by email, however, has a number of risks, both general and specific, that patients should consider before using email.

Risk Factors

Among general email risks are the following:

Email can be immediately broadcast worldwide and be received by many intended and unintended recipients.
Recipients can forward email messages to other recipients without the original sender’s permission or knowledge.
Users can easily misaddress an email.
Email is easier to falsify than handwritten or signed documents.
Backup copies of email may exist even after the sender or the recipient has deleted his or her copy.

Among specific patient email risks are the following:

Email containing information pertaining to a patient’s diagnosis and/or treatment may be included in the patient’s medical or financial records. Thus, all individuals who have access to the medical record or financial record will have access to the email messages.
Employees do not have an expectation of privacy in email that they send or receive at their place of employment. Thus, patients who send or receive email from their place of employment risk having their employer read their email.
If employers or others, such as insurance companies, read an employee’s email and learn of medical treatment, particularly mental health, sexually transmitted diseases, or alcohol and drug abuse information, they may discriminate against the employee/patient. For example, they may fire the employee, not promote the employee, deny insurance coverage, and the like. In addition, the employee could suffer social stigma from the disclosure of such information.
Patients have no way of anticipating how soon Aces Physical Therapy and its employees and agents will respond to a particular email message. Although Aces Physical Therapy and its employees and agents will endeavor to read and respond to email promptly, [Name of Entity] cannot guarantee that any particular email message will be read and responded to within any particular period of time. [Name of Entity]’s employees and agents may be traveling, be engaged in other duties, or be on a vacation or a break and therefore be unable to continually monitor whether they have received email. Thus, patients should not use email in a medical or other emergency.

Conditions for the Use of Email

It is the policy of Aces Physical Therapy to make all email messages sent or received that concern the protected health information (“PHI”), defined as individually identifiable health information that includes medical, financial, demographic, and lifestyle information, part of that patient’s medical, financial, or other records, and Aces Physical Therapy will treat such email messages with the same degree of confidentiality as afforded other portions of the medical record. Aces Physical Therapy will use reasonable means to protect the security and confidentiality of email information. Because of the risks outlined above, Aces Physical Therapy cannot, however, guarantee the security and confidentiality of email communications.

Thus, patients must consent to the use of email for confidential medical information after having been informed of the above risks. Consent to the use of email includes agreement with the following conditions:

All emails to or from the patient concerning diagnosis and/or treatment will be made a part of the patient’s records. As a part of medical record or other records, other individuals, such as other physicians, nurses, physical therapists, patient accounts personnel, and the like, and other entities, such as other health care providers and insurers, may have access to email messages contained in medical records.
Aces Physical Therapy may forward email messages within the facility as necessary for diagnosis, treatment, and reimbursement. Aces Physical Therapy will not, however, forward the email outside the facility without the consent of the patient or as required by law.
If the patient sends an email to Aces Physical Therapy, one of its employees or agents will endeavor to read the email promptly and to respond promptly, if warranted. Aces Physical Therapy, however, can provide no assurance that the recipient of a particular email will read the email message promptly. Because Aces Physical Therapy cannot assure patients that recipients will read email messages promptly, patients must not use email in a medical or other emergency.
If a patient’s email requires or invites a response, and the recipient does not respond within a reasonable time, the patient is responsible for following up to determine whether the intended recipient has received the email and when the recipient will respond.
Because some medical information is so sensitive that unauthorized disclosure can be very damaging, patients should not use email for communications concerning diagnosis or treatment of the following: AIDS/HIV infection; other sexually transmissible or communicable diseases, such as syphilis, gonorrhea, herpes, and the like; mental health or developmental disability; or alcohol and drug abuse.
Because employees do not have a right of privacy in their employer’s email system, patients should not use their employer’s email system to transmit or receive confidential medical information.
Aces Physical Therapy cannot guarantee that electronic communications will be private. Aces Physical Therapy will take reasonable steps to protect the confidentiality of patient email, but Aces Physical Therapy is not liable for improper disclosure of confidential information not caused by Aces Physical Therapy’s gross negligence or wanton misconduct.
If the patient consents to the use of email, the patient is responsible for informing Aces Physical Therapy of any types of information that the patient does not want to be sent by email other than those set out above.
Patient is responsible for protecting patient’s password or other means of access to email sent or received from Aces Physical Therapy to protect confidentiality. Aces Physical Therapy is not liable for breaches of confidentiality caused by patient.
Any further use of email by the patient that discusses diagnosis or treatment by the patient constitutes informed consent to the foregoing. You may withdraw consent to the future use of email at any time by email or written communication to Aces Physical Therapy, attention: Brian Mello.

HIPAA Documents Resource Center CD, 6th ed.