Acknowledgement of Online Interaction Policy
PATIENT ACKNOWLEDGEMENT AND CONSENT TO ONLINE INTERACTION POLICIES
I wish to use Internet-based communications, registration and other Internet-based modes of interaction to facilitate my
receipt of health care from this practice.
Benefits and Risks:
1. I understand that the benefits of Online Interaction include being able to take advantage of the expertise of
a physician who may not be physically available to provide health care, and access to sources of
information suggested by my own physician.
2. I understand that there are potential risks associated with receiving health care through Online Interaction,
including for example, timeliness of the interactions and the inability of a physician to give me a complete
physical examination. Consequently, there is a risk that a physician may not be able to determine the proper
diagnosis and treatment based upon Online Interaction.
3. I understand that the practice specifically reserves the right to withhold conclusions of diagnosis and/ or
recommendations for treatment based upon information obtained via Online Interaction in the absence of
an in-person encounter, and that I am not to interpret any comments of my physician(s) or the staff as a
diagnosis or specific treatment instruction under those conditions, unless my personal physician specifically
indicates that I should.
4. I understand that general information to which my physician(s) may refer me, or that which may be available
on their Web sites, is not to be used for purposes of self-diagnosis or self-treatment, and to the extent that I
do so I release my physician(s) and the practice and hold them harmless.
Confidentiality and Security of Information:
1. I understand that all state and federal rules and regulations governing confidentiality of my medical records
and access to my Personally Identifiable Health Information (including my ability to obtain copies of my
records) will apply to services provided through Online Interaction and to the electronic transmission and
storage of my Personally Identifiable Health Information.
2. I understand that my physician(s) and the practice will not give any images or information that identifies me
and was obtained through Online Interaction to other entities without my consent unless permitted to do so
under applicable laws or unless required to do so as part of a legal action. I have read and understand the
privacy policy of the practice as published on its website.
3. I understand that when I conduct Online Interaction with the practice.s staff, I am subject to the privacy,
confidentiality, and information security policies of those third parties and I have had the opportunity to
review said policies.
4. I understand that despite best efforts of all involved parties, there remains some amount of risk of
inappropriate disclosure of my personal information, and I agree to hold the practice harmless for such
disclosures when they occur as the result of acts or omissions of third parties. Use of .Electronic Mail.
5. I understand and agree that I am not to use the secure messaging service in emergency or other timecritical
situations.
6. I understand that the practice and its physicians discourage the use of standard e-mail for communicating
about personal health issues, because standard e-mail is not a secure communications mechanism and
does not provide structured forms of communication. Instead, the practice uses a secure, healthcareoriented
messaging service from Waiting Room Solutions, LLC.
7. I understand that while I should not use regular e-mail to communicate to my physician and his/ her staff
about personal health matters, standard e-mail may be used by the practice for purposes such as sending
me notification of new messages that have been sent to my secure mailbox, or non- personal types of
communications such as informing me of changes to office policies I understand and agree that I am to use
appropriate language and tone in my messages and other Online Interaction, and in particular I am to avoid
any language that abuses, mocks, belittles, or attacks the recipient or is in any way libelous to third parties.
According to the Privacy Act of 1974 and court rulings, employers generally have the legal right to access
any e- mail received or sent by a person at work. I understand generally that I should not communicate with
the practice (including my physician(s) and staff, and including via standard e-mail) using computers or
networks of my employer.
8. I understand that online communications alone are not sufficient for proper medical care.
9. I understand that my physician may refuse to continue online discussion of a condition when he or she
believes an in-person encounter is appropriate.
10. I understand that in no case should I expect my physician to deliver a conclusion of diagnosis, a
recommendation for treatment, or a prognosis regarding a complaint or symptom for which I have not been
seen in person, or regarding a condition for which I have not been seen in person within the previous 20
days.
11. I understand that I am to keep copies of messages received from my physician.
12. I understand that my physician will retain copies of our communications within my medical record.
13. I understand that if my username and password is obtained by another individual, including an unauthorized
family member, I am to notify the practice immediately and at the earliest opportunity should return to the
practice or its website to establish a new username and password. Physician May Discontinue the Online
Relationship.
14. I understand that my physician may discontinue his or her Online Interaction with me under any
circumstance in which he or she believes that I have used Online Interaction in a manner that is
inconsistent with his or her policies as stated herein.
15. I understand that I will be notified of such termination of Online Interaction Ownership of Information.
16. I understand that neither the practice nor my physician(s) make any claim of legal ownership of the
electronic information that is exchanged via Online Interaction and stored by third- party providers of online
services.
17. I also understand that there are no current conclusions of law that would hold that the information is legally
owned by me, by the practice, my physician(s), or the vendors of the online services used to create and
store the information. However, I understand that I do have rights of access to the information, and rights of
refusal to disclosures of the information.
Consent:
I hereby consent to obtaining some aspects of my health care from the practice using Internet-based communications or
other Internet-based modes of interaction (.Online Interaction.), and I further consent to the electronic transmission and
storage of my Personally Identifiable Health Information. I understand that I may withdraw this consent at any time without
affecting my right to future care or treatment or risking loss or withdrawal of any program benefits to which I would
otherwise be entitled. My physician has provided me with the opportunity to discuss and to question the issues, risks, and
policies set forth in this consent form. I fully understand the information provided.
I wish to use Internet-based communications, registration and other Internet-based modes of interaction to facilitate my
receipt of health care from this practice.
Benefits and Risks:
1. I understand that the benefits of Online Interaction include being able to take advantage of the expertise of
a physician who may not be physically available to provide health care, and access to sources of
information suggested by my own physician.
2. I understand that there are potential risks associated with receiving health care through Online Interaction,
including for example, timeliness of the interactions and the inability of a physician to give me a complete
physical examination. Consequently, there is a risk that a physician may not be able to determine the proper
diagnosis and treatment based upon Online Interaction.
3. I understand that the practice specifically reserves the right to withhold conclusions of diagnosis and/ or
recommendations for treatment based upon information obtained via Online Interaction in the absence of
an in-person encounter, and that I am not to interpret any comments of my physician(s) or the staff as a
diagnosis or specific treatment instruction under those conditions, unless my personal physician specifically
indicates that I should.
4. I understand that general information to which my physician(s) may refer me, or that which may be available
on their Web sites, is not to be used for purposes of self-diagnosis or self-treatment, and to the extent that I
do so I release my physician(s) and the practice and hold them harmless.
Confidentiality and Security of Information:
1. I understand that all state and federal rules and regulations governing confidentiality of my medical records
and access to my Personally Identifiable Health Information (including my ability to obtain copies of my
records) will apply to services provided through Online Interaction and to the electronic transmission and
storage of my Personally Identifiable Health Information.
2. I understand that my physician(s) and the practice will not give any images or information that identifies me
and was obtained through Online Interaction to other entities without my consent unless permitted to do so
under applicable laws or unless required to do so as part of a legal action. I have read and understand the
privacy policy of the practice as published on its website.
3. I understand that when I conduct Online Interaction with the practice.s staff, I am subject to the privacy,
confidentiality, and information security policies of those third parties and I have had the opportunity to
review said policies.
4. I understand that despite best efforts of all involved parties, there remains some amount of risk of
inappropriate disclosure of my personal information, and I agree to hold the practice harmless for such
disclosures when they occur as the result of acts or omissions of third parties. Use of .Electronic Mail.
5. I understand and agree that I am not to use the secure messaging service in emergency or other timecritical
situations.
6. I understand that the practice and its physicians discourage the use of standard e-mail for communicating
about personal health issues, because standard e-mail is not a secure communications mechanism and
does not provide structured forms of communication. Instead, the practice uses a secure, healthcareoriented
messaging service from Waiting Room Solutions, LLC.
7. I understand that while I should not use regular e-mail to communicate to my physician and his/ her staff
about personal health matters, standard e-mail may be used by the practice for purposes such as sending
me notification of new messages that have been sent to my secure mailbox, or non- personal types of
communications such as informing me of changes to office policies I understand and agree that I am to use
appropriate language and tone in my messages and other Online Interaction, and in particular I am to avoid
any language that abuses, mocks, belittles, or attacks the recipient or is in any way libelous to third parties.
According to the Privacy Act of 1974 and court rulings, employers generally have the legal right to access
any e- mail received or sent by a person at work. I understand generally that I should not communicate with
the practice (including my physician(s) and staff, and including via standard e-mail) using computers or
networks of my employer.
8. I understand that online communications alone are not sufficient for proper medical care.
9. I understand that my physician may refuse to continue online discussion of a condition when he or she
believes an in-person encounter is appropriate.
10. I understand that in no case should I expect my physician to deliver a conclusion of diagnosis, a
recommendation for treatment, or a prognosis regarding a complaint or symptom for which I have not been
seen in person, or regarding a condition for which I have not been seen in person within the previous 20
days.
11. I understand that I am to keep copies of messages received from my physician.
12. I understand that my physician will retain copies of our communications within my medical record.
13. I understand that if my username and password is obtained by another individual, including an unauthorized
family member, I am to notify the practice immediately and at the earliest opportunity should return to the
practice or its website to establish a new username and password. Physician May Discontinue the Online
Relationship.
14. I understand that my physician may discontinue his or her Online Interaction with me under any
circumstance in which he or she believes that I have used Online Interaction in a manner that is
inconsistent with his or her policies as stated herein.
15. I understand that I will be notified of such termination of Online Interaction Ownership of Information.
16. I understand that neither the practice nor my physician(s) make any claim of legal ownership of the
electronic information that is exchanged via Online Interaction and stored by third- party providers of online
services.
17. I also understand that there are no current conclusions of law that would hold that the information is legally
owned by me, by the practice, my physician(s), or the vendors of the online services used to create and
store the information. However, I understand that I do have rights of access to the information, and rights of
refusal to disclosures of the information.
Consent:
I hereby consent to obtaining some aspects of my health care from the practice using Internet-based communications or
other Internet-based modes of interaction (.Online Interaction.), and I further consent to the electronic transmission and
storage of my Personally Identifiable Health Information. I understand that I may withdraw this consent at any time without
affecting my right to future care or treatment or risking loss or withdrawal of any program benefits to which I would
otherwise be entitled. My physician has provided me with the opportunity to discuss and to question the issues, risks, and
policies set forth in this consent form. I fully understand the information provided.