Email Informed Consent Form


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:

Among specific patient email risks are the following:

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:

HIPAA Documents Resource Center CD, 6th ed.

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