Drs. Cellupica and Witt (hereafter known as “the Physicians”) offer patients the opportunity to communicate by email.  Transmitting patient information poses several risks, of which the patient should be aware.  The patient should not agree to communicate with the physician without understanding and accepting these risks.  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 email that pass through their servers.

• Email is easier to falsify than handwritten or signed hard copies.  In addition, it is impossible to verify the true identity of the sender or to ensure that only the recipient can read the email once it has been sent.

• Emails can introduce viruses in 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 Physicians or the patient.  Email senders can easily misaddress an email resulting in it being sent to many 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.

• Email can be used as evidence in court.

• The Physicians do not use encryption software.  The patient understands that this increases the risk of violation of a patient’s privacy.

 

The Physicians will use reasonable means to protect the security and confidentiality of email information sent and received.  However, because of the risks outlined above, the Physicians cannot guarantee the security and confidentiality of email communication and will not be liable for improper disclosure of confidential information that is not the direct result of intentional misconduct of the Physicians.  Thus, patients must consent to the use of email for 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.

• The Physicians may forward email internally to the Physicians’ staff and to those involved as necessary for diagnosis, treatment, reimbursement, health care operations and other handling.  The Physicians will not however forward emails to independent third parties without the patient's prior written consent, except as authorized or required by law.

• Although the Physicians will endeavor to read and respond promptly to an email from the patient, the Physicians cannot guarantee that any particular email will be read and responded to within any particular period of time.  Thus, the patient should not use email for medical emergencies or other time-sensitive matters.  Emails are typically not answered between 11:00pm and 8:00am.

• Email communication is not an appropriate substitute for clinical examinations.  The patient is responsible for following up on the Physicians’ email and for scheduling appointments where warranted.

• If the patient’s email requires or invites a response from the Physicians and the patient has not received a response within 24 hours, it is the patient’s responsibility to follow-up and determine whether the intended recipient received the email and when the recipient will respond.

• The patient should exercise caution in communicating with the Physician regarding sensitive medical information, such as a diagnosis or a topic such as sexually transmitted infection, HIV/AIDS, mental health, developmental disability, or substance abuse.  Similarly, the Physicians may refuse to discuss such matters over email.

• The Physicians are not responsible for information loss due to technical failures.

 

Instructions for Communication by Email

 

The Caregiver/Patient shall:

• Inform the Physicians of any changes in the patient’s email address.

• Include the patient’s full name and age, along with a brief description of the problem.  Emails received without all of the above information may not be answered.

• Take precautions to preserve the confidentiality of emails such as using screen savers and safeguarding passwords.

• Withdraw this consent only by email or written communication to the Physician.

• Should the patient require immediate medical assistance, or if the patient’s condition appears serious or rapidly worsens, the patient should not rely on email.  Rather, the patient should call the Physician’s office for consultation or an appointment, visit the Physician’s office, or take other measures as appropriate.

 

Patient’s Acknowledgement and Agreement

I acknowledge that I have read and fully understand this consent form.  I understand that this contract is with my own doctor only and emails shall not be sent to other Pediatricians in this practice.  I understand that during vacation times this service may not be available.  I understand that advice will be communicated back to me via email or phone depending on my doctor’s availability on an “as soon as convenient” basis and typically within 24 hours, however the Physicians cannot guarantee that any particular email will be read and responded to within any particular period of time.  I will not hold my Physician or anyone associated with my Physician or Pivotal Kids Clinic responsible for delays in urgent medical care resulting in medical complications for my child.  I understand that any advice given reflects opinion rendered based on an assessment of my own question and is not a substitute for traditional medical care of my child.  I understand the risks associated with the communication of email between me and the Physicians, and consent to the conditions outlined herein, as well as any other instructions that the Physicians may impose to communicate with patients by email.  I acknowledge the Physicians right to, upon provision of written notice, withdraw the option of communicating through email.  I understand that the following circumstances may result in immediate termination of email service for my family as determined by my Physician, without removing responsibility for payment for all prior emails:

 

• False representation and identification of patient or family

• Abusive or confrontational language

• Email directed to a Pediatrician other than your own Pediatrician

• Failure to pay for any charges related to email services within a reasonable period of time

• Overuse of service or improper demands upon the service.  The Physician will discuss this issue with you prior to termination of the service.

 

I understand that this is an uninsured medical service and agree to pay all charges related to each email sent as listed under Uninsured Services unless prepaid via an annual fee.

 

Any questions I may have had were answered.

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