Email Consent Form

Before sending Email to Richmond Eye Associates, read and agree to the following information regarding the risks and conditions of Email use:

1. Risk of Using Email

Richmond Eye Associates offers patients and other individuals the opportunity to communicate by Email. However, transmitting patient information by Email has a number of risks that should be considered. These include, and are not limited to, the following risks:

• Email can be circulated, forwarded, and stored in numerous paper and electronic files.

• Email can be immediately broadcast worldwide and be received by many intended and unintended recipients.

• Email senders can easily misaddress an Email.

• Email is easier to falsify than handwritten or signed documents.

• Backup copies of Email may exist even after sender or recipients have deleted their copy.

• Employers and on-line services have a right to archive and inspect Emails transmitted through their systems.

• Email can be intercepted, altered, forwarded, or used without authorization or detection.

• Email can be used as evidence in court.

2. Conditions for the Use of Email

Richmond Eye Associates will use reasonable means to protect the security and confidentiality of Email information sent and received. However, because of the risks outlined above, Richmond Eye Associates cannot guarantee the security and confidentiality of Email communication, and will not be liable for improper disclosure of confidential information that is not caused by Richmond Eye Associate's intentional misconduct. Thus, individuals must consent to the use of Email for information. Consent to the use of Email includes agreement with the following conditions:

• All Emails to or from Richmond Eye Associates patients concerning diagnosis or treatment will be printed out and made part of 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.

• Richmond Eye Associates may forward Emails internally to the practice's staff and agents as necessary for diagnosis, treatment, reimbursement, and other handling. Richmond Eye Associates will not, however, forward Emails to independent third parties without the patient's prior written consent, except as authorized or required by law.

• Although Richmond Eye Associates will endeavor to read and respond promptly to an Email, Richmond Eye Associates cannot guarantee that any particular Email will be read and responded to within any particular period of time. Thus, no one shall use Email for medical emergencies or other time-sensitive matters.

• If the individual's Email requires or invites a response from Richmond Eye Associates, and the individual has not received a response within a reasonable time period, it is the individual's responsibility to follow up to determine whether the intended recipient received the Email and when the recipient will respond.

• Individuals should not use Email for communication regarding sensitive medical information such as information regarding sexually transmitted diseases, AIDS/HIV, mental health, developmental disability, or substance abuse.

• Individuals are responsible for informing Richmond Eye Associates of any types of information that they desire not to be sent by Email, in addition to those out in the above paragraph.

• The individual is responsible for protecting his/her password or other means of access to Email. Richmond Eye Associates is not liable for breaches of confidentiality caused by the individual or any third party.

• Richmond Eye Associates shall not engage in Email communication that is unlawful, such as unlawfully practicing medicine across state lines.

• It is the individual's responsibility to follow up and/or schedule an appointment if warranted.

 

3. Communicating by Email

To communicate by Email, patients and other individuals shall:

• Limit or avoid the use of his/her employer's computer.

• Inform Richmond Eye Associates of changes in his/her Email address.

• If the sender is a patient of Richmond Eye Associates, to put the patient's name in the body of the Email.

• Review the Email to make sure that it is clear and that all relevant information is provided before sending to Richmond Eye Associates.

• Take precautions to preserve the confidentiality of Email, such as using screen savers and safeguarding his/her computer password.

• Withdraw consent only be Email or written communication to Richmond Eye Associates.

4. Acknowledgment and Agreement

I acknowledge that I have read and fully understood this consent form. I understand the risks associated with the communication of Email between Richmond Eye Associates and me, and consent to the conditions outlines herein. In addition, I agree to the instructions for communicating by Email outlined herein, as well as any other instructions that Richmond Eye Associates may impose to communicate using Email.