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Using Email as Communication

Patient E-mail Consent


Transmitting patient information by E-mail has a number of risks

These risks include, but are not limited to, the following:

a) ​The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) recommends that E-mail that contains protected health information be encrypted. E-mails sent from Amaranth Pediatric Health, P.C. (herein known as “Practice”) may not be encrypted during electronic transmission, so the content of such e-mails may not be secure. Therefore it is possible that the confidentiality of such communications may be breached by a third party.

b) E-mail can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients.

c) E-mail is easier to falsify than handwritten or signed documents.


d) Backup copies of e-mail may exist even after the sender or the recipient has deleted his or her copy.

e) Employers and on-line services have ​a ​right to inspect e-mail transmitted through their systems.

f) E-mail can be intercepted, altered, forwarded, or used without authorization or detection.

g) E-mail can be used to introduce viruses into computer systems. Practice server could go down and E-mail would not be received until the server is back on-line.


Security is all of our responsibility

To communicate by E-mail, the patient shall:

a)  Avoid use of his/her employer's computer.

b)  Key in the topic (​e.g​., medical question, billing question) in the subject line.

c)  Inform Practice of changes in his/her E-mail address.

d)  Acknowledge any E-mail received from the Practice and/or Physician.

e)  Take precautions to preserve the confidentiality of E-mail.

g)  Protect his/her password or other means of access to E-mail.


A working relationship

I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communication of E-mail between the Practice, Physician and me, and consent to the conditions and instructions outlined, as well as any other instructions that the Practice may impose to communicate with patient by E-mail. If I have any questions, I may inquire with the relevant officer at Practice.

I, for myself, my heirs, executors, administrators and assigns, fully release and discharge ​Amaranth Pediatric Health, P.C. ​and its officers, directors, physicians, and employees, from and against any and all losses, claims, and liabilities arising out of or connected with the use of such e-mail.


We will use reasonable means to maintain security and confidentiality of E-mail information sent and received.

Practice and Physician are not liable for improper disclosure of confidential information that is not caused by Practice's or Physician’s intentional misconduct.


Patients must acknowledge and consent to the following conditions:

a) ​E-mail is not appropriate for urgent or emergency situations. Practice and Physician cannot guarantee that any particular e-mail will be read and responded to within any particular period of time. Please do not send us medical requests (eg, prescription refill, sick visit appointment, well visit appointment, or anything of urgent matter) via e-mail. Patient recognizes e-mail is not the appropriate venue for such communication purposes.

b) ​Please call us should you attach any documents to an e-mail to our office. If the patient’s e-mail requires or invites a response from Practice or Physician, it is the patient’s responsibility to follow-up to determine whether the intended recipient received the e-mail and when the recipient will respond.

c) E-mail shall be concise with short questions. The patient should schedule an appointment if the issue is too complex or sensitive to discuss via e-mail.

d) Office staff will receive and read your messages.

e) Practice will not forward patient identifiable e-mails outside of the Practice without the patient's prior consent, except as authorized or required by law.

f) The patient should not use e-mail for communication regarding sensitive medical information, such as information regarding sexually transmitted diseases, AIDS/HIV, mental health, or substance abuse. Practice is not liable for breaches of confidentiality caused by the patient or any third party.

g) It is the patient's responsibility to follow up and/or schedule an appointment if warranted.

h) This consent will remain in effect until terminated in writing by either the patient or Practice.

i) In the event that the patient does not

comply with the conditions herein, Practice may terminate patient’s privilege to communicate by e-mail with Practice.

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