Patient Consent for Use of Electronic Mail / Terms and Conditions:

RISK OF USING E-MAIL:

North Shore Pain Management offers patients the opportunity to communicate with clinicians by e-mail. Transmitting patient information by e-mail, however, has a number of risks that patients should consider before giving consent. These risks include, but are not limited to:

• E-mail can be circulated, forwarded, and stored innumerous paper and electronic files.
• E-mail senders can misaddress e-mail.
• E-mail can be more easily falsified than handwritten or signed documents.
• Backup copies of e-mail may exist even after the sender or the recipient has deleted his or her copy.
• Employers and on-line services have a right to archive and inspect e-mails transmitted through their systems.
• 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.

CONDITIONS FOR THE USE OF E-MAIL:

• North Shore Pain Management will use reasonable means to protect the security and confidentiality of e-mail information sent and received. However, because of the risks outlined above. North Shore Pain Management cannot guarantee the security and confidentiality of e-mail communication, and will not be liable for improper disclosure of confidential information that is not caused by Provider’s intentional misconduct. Thus, patients must consent to the use of e-mail for patient information. Consent to the use of e-mail includes agreement with the following conditions:
• All e-mails to or from the patient concerning diagnosis or treatment will be printed out and made part of the patient’s medical record. Because they are a part of the medical record, other individuals authorized to access the medical record, such as staff and billing personnel will have access to those e-mails.
• North Shore Pain Management may forward e-mails internally to North Shore Pain Management’ staff and agents as necessary for diagnosis, treatment, reimbursement, and other handling. North Shore Pain Management will not, however, forward e-mails to independent third parties without the patient’s prior written consent, except as authorized or required by law.
• Although North Shore Pain Management will endeavor to read and respond promptly to an e-mail from the patient. North Shore Pain Management cannot guarantee that any particular e-mail will be read and responded to within any particular period of time. Thus, the patient shall not use e-mail for medical emergencies or other time-sensitive matters.
• If the patient’s e-mail requires or invites a response from North Shore Pain Management and the patient has not received a response within a reasonable time period, 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.
• The patient should not use e-mail for communication regarding sensitive medical information, such as information regarding sexually transmitted diseases, AIDS/HIV, mental health, developmental disability, or substance abuse.
• The patient is responsible for informing North Shore Pain Management of any types of information the patient does not want to be sent by e-mail, in addition to those set out in 2(e) above.
• The patient is responsible for protecting his/her password or other means of access to e-mail. North Shore Pain Management is not liable for breaches o confidentiality caused by the patient or any third party.
• North Shore Pain Management shall not engage in e-mail communication that is unlawful, such as unlawfully practicing medicine across state lines.
• It is the patient’s responsibility to follow up and/or schedule an appointment if warranted.

INSTRUCTIONS:

To communicate by e-mail, the patient shall:

• Limit or avoid use of his/her employer’s computer.
• Inform North Shore Pain Management of changes in his/her e-mail address.
• Put the patient’s name in the body of the e-mail.
• Include the category of the communication in the e-mail’s subject line, for routing purposes (e.g., billing question).
• Review the e-mail to make sure it is clear and that all relevant information is provided before sending to Provider.
• Inform North Shore Pain Management that the patient received e-mail from North Shore Pain Management.
• Take precautions to preserve the confidentiality of e-mails, such as using screen savers and safeguarding his/her computer password.
• Withdraw consent only by e-mail or written communication to Provider.

PATIENT ACKNOWLEDGMENT 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 between Provider and me, and consent to the conditions outlined herein. In addition, I agree to the instructions outlined herein, as well as any other instructions that Provider may impose to communicate with patients by e-mail. Any questions I may have had were answered.