Informed Consent for E-Mail or Text Communication

Record #

Informed Consent for E-Mail or Text Communication

The use of e-mail and/or text communication can improve the ability to exchange information quickly and efficiently between you and your mental health care provider.  To share Personal Health Information (PHI), we request that you only use encrypted e-mail.  For our practice, we have chosen the encrypted e-mail service from ProtonMail (free of charge: https://protonmail.com/), sent directly to our ProtonMail addresses from your ProtonMail address, whenever communicating with us via encrypted e-mail.  The confidentiality of the information exchanged by regular e-mail and/or text messages is not guaranteed.  Regular e-mail messages and/or text messages sent are not encrypted and can potentially be misdirected or intercepted by unintended parties.  In addition:

  • E-mail and/or text messages may be processed by staff other than your health care provider.
  • E-mail and/or text messages sent to workplace e-mail and/or text addresses may be monitored by employers who may have the right to monitor all workplace e-mail and/or text communications.
  • E-mail and/or text messages or relevant information from the message may be filed in your health record by your health care provider.

Please review the following guidelines outlining the acceptable use of e-mail and text messages between clients and health care providers within our practice.

  • Use only the encrypted e-mail service from ProtonMail sent directly to our ProtonMail addresses, whenever communicating with us by e-mail, and especially when sending Personal Health Information (PHI).
  • Do not use regular e-mail or text messages for information you consider sensitive and would not want shared with anyone except your mental health care provider.  Use the recommended encrypted e-mail service from ProtonMail, above.
  • Do not use e-mail or text messages for urgent matters.  Your mental health care provider may be away from the workplace or may not be able to check e-mail or text messages daily.  Another method of communication should be used, such as the phone.
  • Put your full name and contact information in the body of your message.  This will ensure your mental health care provider knows which client has sent the message.
  • Keep a copy of the e-mail or text messages you send and/or receive.

IMPORTANT NOTICES:

If required, call Dr. Pacheco, his Assistants, and/or Associates and, if not available immediately, please leave a voice mail message with your name, telephone number, and a brief description of the situation.  Your call will be answered as soon as possible.

In the event of an emergency, call 911, or go to the nearest Hospital Emergency Room, where you will be assisted.

By signing this form, I confirm that:

  • I have had the opportunity to ask any questions about the preceding information;
  • I consent to and will follow the guidelines listed above;
  • I consent to the use of e-mail and/or text messages;
  • I consent to and agree to use ProtonMail encrypted e-mail, to and from our ProtonMail addresses, whenever communicating with you by e-mail, and especially when sending Personal Health Information (PHI).
  • I consent to the use of encrypted e-mail messages for matters relating to scheduling, changing, and/or cancelling appointments;
  • I agree to accept, as outlined above, e-mail and/or text messages from Dr. Pacheco, his Assistants, and/or Associates;
  • I accept full responsibility for such communications;
  • I acknowledge receipt of a copy of this document, of the Privacy and Confidentiality Policy Summary, and of the Privacy Policy; and,
  • In addition, for the sending/receiving of Professional Service Statements and matters thereof, my(our) preference is [Check/Complete Only One]:

0 E-Mail: __________________________________________________________________________________________________________

0 Fax:  ____________________________________________________________________________________________________________

0 Postal Service:  __________________________________________________________________________________________________

Office Pick-Up by Prior Arrangement

 

ACCEPTED IN ACCORDANCE:

Printed Name                                                             Signature                                                             Date

 

 

 

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