Email Consent Form

Although Diamond Women's Center, P.A. has a policy of not recommending communication via e-mail with our patients, we acknowlege that it is increasingly becoming a popular communication forum. Therefore, we ask that you read this consent thoroughly to fully understand the potential risks, conditions and instructions before you make the choice whether or not to communciate any information via e-mail.

Risks of Using E-Mail

Diamond Women's Center, P.A. offers patients the opportunity to communicate by e-mail. However, transmitting patient information by e-mail has a number of risks that patients should consider. These include, but are not limited to the following risks:

1. E-mail can be circulate, forwarded, and stored in numerous paper and electronic files.
2. E-mail can be immediately broadcast worldwide and be received by many intended and unintended recipients.
3. E-mail senders can easily misaddress an e-mail.
4. E-mail is easier to falsify than handwritten or signed documents.
5. Backup copies of e-mail may exist even after senders or recipients have deleted their copy.
6. Employers and on-line services have a right to archive and inspect e-mails transmitted through their systems.
7. E-mail can be intercepted, altered, forwarded, or used without authorization or detection.
8. E-mail can be used as evidence in court.

Conditions for the use of E-mail

Diamond Women's Center, P.A. will use reasonable means to protect the security and confidentiality of e-mail information sent and received. However, because of the risks outlined above, Diamond Women's Center, P.A. cannot guarantee the security or confidentiality of e-mail communication, and will not be liable for improper disclosure of confidential information that is not caused by Diamond Women's Center, P.A.'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:

1. All e-mails to or from the patient concerning diagnosis or treament will be printed out and made part of the patient's medical record. Beacuse 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.
2. Diamond Women's Center, P.A., may forward e-mails internally to the practice's staff and agents as necessary for diagnosis, treatment, reimbursement and other handling. Diamond Women's Center, P.A. will not , however, forward e-mails to independent third parties without the patient's prior written consent, except as authroized or required by law.
3. Althought Diamond Women's Center. P.A. will endeavor to read and respond promptly to an e-mail from the patient, Diamond Women's Center, P.A. cannot guarantee that any particular e-mail will be read and responded to in any particular period of time. Thus, the patient shall not use e-mail for medical emergences or time-sensitve matters.
4. If the patient's e-mail requires or invites a response from Diamond Women's Center, P.A. and the patient has not received a response within a reasonable time period, within 72 hours, it is the patient's responsibility to follow up to determine whether the inteded recipient received the e-mail and when the recipient will respond.
5. The patient should not use e-mail for communciation regarding sensitive medical information such as information regarding sexually transmitted diseases, AIDS/HIV, mental health, developmental disability or substance abuse.
6. The patient is responsible for informing Diamond Women's Center, P.A. of any types of information the patient does not want sent by e-mail, in addition to those set out in Conditions for using e-mail #5.
7. The patient is responsible for protecing his/her password or other means of access to e-mail. Diamond Women's Center, P.A. is not liable for breaches of confientiality caused by the patient or any third party.
8. Diamond Women's Center, P.A. shall not engage in e-mail communication that is unlawful, such as unlawfully practicing medicine across state lines.
9. It is the patient's responsibility to follow up and/or schedule an appointment as warranted.

Instructions

To communicate by e-mail the patient shall

1. Avoid use of her employer's computer.
2. Inform Diamond Women's Center, P.A. of changes in her e-mail address.
3. Put the patient's full name and birth date in the body of the e-mail.
4. Include the category of communcation in the e-mail subject line, for routing purposes.
5. Review the e-mail to make sure it is clear and that all relevant information is provided before sending to Diamond Women's Center, P.A.
6. Take precautions to preserve the confidentiality of e-mails, such as using screen savers and safeguarding her computer password.
7. Withdraw consent only by e-mail or written communcation to Diamond Women's Center, P.A.
8. Observe any and all guidelines and/or restrictions which Diamond Women's Center, P.A. may impose.