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===================== E-MAIL CONSENT FORM ===================== RISKS OF USING E-MAIL Bristol Park Medical offers patients the opportunity to communicate by e-mail. Transmitting patient information by e-mail, however, has a number of risks that patients should consider before using e-mail. These include, but are not limited to, the following: 1. E-mail can be circulated, 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. Back-up copies of e-mail may exist even after the sender or the recipient has deleted his or her 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 to introduce viruses into computer systems. 9. E-mail can be used as evidence in court. CONDITIONS FOR THE USE OF E-MAIL Bristol Park Medical will use reasonable means to protect the security and confidentiality of e-mail information sent and received. However, because of the risks outlined above, Bristol Park Medical cannot guarantee the security and confidentiality of e-mail communication, and will not be liable for improper disclosure of confidential information that is not caused by Bristol Park Medical'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 treatment will be printed out 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 e-mails. 2. Bristol Park Medical providers may forward e-mails internally to Bristol Park Medical's staff and agents as necessary for diagnosis, treatment, reimbursement or other handling. Bristol Park Medical will not, however, forward e-mails to independent third parties without the patient's prior written consent, except as authorized or required by law. 3. Although Bristol Park Medical will endeavor to read and respond promptly to an e-mail from the patient, Bristol Park Medical cannot guarantee that any particular e-mail will be read and responded to within any particular period of time. Thus, the patient shall not use e-mail for medical emergencies or other time-sensitive matters. 4. If the patient's e-mail requires or invites a response from Bristol Park Medical, and the patient has not received a response within a reasonable time period, it is the patient's responsibility to follow up to determine whether the intended recipient received the e-mail and when the recipient will respond. 5. The patient should not use e-mail for communication 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 Bristol Park Medical of any types of information the patient does not want to be sent by e-mail, in addition to those set out above. 7. The patient is responsible for protecting his/her password or other means of access to e-mail. Bristol Park Medical is not liable for breaches of confidentiality cause by the patient or any third party. 8. Bristol Park Medical 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 if warranted. INSTRUCTIONS To communicate by e-mail, the patient shall: 1. Limit or avoid use of his/her e-mail address. 2. Inform Bristol Park Medical of changes in his/her e-mail address. 3. Put the patient's name in the body of the e-mail. 4. Include the category of the communication in the e-mail's subject line, for routing purposes (e.g., billing question, appointment request). 5. Review the e-mail to make sure it is clear and that all relevant information is provided before sending to Bristol Park Medical. 6. Inform Bristol Park Medical that the patient received an e-mail from Bristol Park Medical. 7. Take precautions to preserve the confidentiality of e-mails, such as using screen savers and safeguarding his/her computer password. 8. Withdraw consent only by e-mail or written communication to Bristol Park Medical. ACKNOWLEDGEMENT I acknowledge that I have read and fully understand the risks and conditions associated with the communication of e-mail between Bristol Park Medical and me, and consent to the conditions outlined herein. In addition, I agree to the instructions that Bristol Park Medical may impose to communicate with patients by e-mail. *  I Accept the above E-Mail Consent Terms