HIPPA Email & Phone Consent

402 Main St Suite 3 North Houston, TX 77002
HIPPA Email & Phone Consent

Email and Phone Communication Consent Form, Updated September

Please carefully read the following consent form about email and phone consent communication from Wellness For Humanity regarding Covid testing results. Once you have read the information please sign the form to indicate that you agree to the conditions in this consent form. If a signed consent if not present in your chart, we will not use emails to communicate with you.

Risks of using email While the opportunity to communicate by email enhances your care, transmitting patient information poses several risks of which you should be aware. The risks include, but are not limited to, the following:

• The privacy and security of email communication cannot be guaranteed.
• Employers and online services may have a legal right to inspect and keep emails that pass through their system.
• Emails can introduce viruses into a computer system, and potentially damage or disrupt the computer.
• Email can be forwarded, intercepted, circulated, stored or even changed without the knowledge or permission of the Wellness Center or the patient. Email senders can easily misaddress an email, resulting in it being sent to unintended and unknown recipients.
• Email is indelible. Even after the sender and recipient have deleted their copies of the email, back-up copies may exist on a computer or in cyberspace.
• Use of email to discuss sensitive information can increase the risk of such information being disclosed to third parties.

Conditions of Using Email Or Phone Call: Wellness For Humanity will use reasonable means to protect the security and confidentiality of email information sent and received. However, because of the risks outlined above, the physician cannot guarantee the security and confidentiality of email communication. Therefore your consent is required to use email for transfer of patient information. Consent to the use of email includes agreement with the following conditions:

• Emails to or from the patient concerning diagnosis or treatment may be printed in full and made part of the patient’s medical record. Because they are part of the medical record,
other individuals authorized to access the medical record, such as staff and billing personnel, will have access to those emails authorized or required by law.
• If your email requires or invites a response from the physician and you have not received a response within a reasonable time period it is the your responsibility to follow up to
determine whether the intended recipient received the email and when the recipient will respond.
• If you have any concerns about medical information being sent by email you should not consent to email communication.
• The physician is not responsible for information loss due to technical failures associated with the patient’s email software or internet service provider
Instructions for communication by phone:
• A phone call will be placed to discuss your results. If you consent please know we will call the number provided on your appointment. Please let us know if you do not want results discussed over the phone.

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 email between the physician and me, and consent to the conditions outlined herein, as well as any other instructions that the physician may impose to communicate with patients by email. I acknowledge the physician’s right to, upon the provision of written notice, withdraw the option of communicating through email. Any questions I may have had were answered.