Informed Consent

Informed Consent Regarding e-mail or the internet use of protected personal information.

Wellness Alternatives provides patients the opportunity to communicate with their physician, health care providers, and administrative staff by e-mail. Transmitting confidential health information by e-mail, however, has a number of risks, both general and specific, that should be considered before using e-mail.

1. Risks o General e-mail risks are the following: e-mail can be immediately broadcast worldwide and be received by many intended and unintended recipients can forward e-mail messages to other recipients without the original sender(s) permission or knowledge; users can easily misaddress an e-mail; e-mail is easier to falsify than handwritten or signed documents; backup copies of e-mail may exist even after the sender or the recipient has deleted his/her copy. o Specific e-mail risks are the following: e-mail containing information pertaining to diagnosis and/or treatment must be included in the protected health information; all individuals who have access to the protected personal health information will have access to the e-mail messages; patients who send or receive e-mail from their place of employment risk having their employer read their email.

2. It is the policy of Wellness Alternatives that all e-mail messages sent or received which concern the diagnosis or treatment of a patient will be part of that patient’s protected personal health information and will treat such e-mail messages or internet communication with the same degree of confidentiality as afforded other portions of protected health information. Wellness Alternatives will use reasonable means to protect the security and confidentiality of e-mail or internet communication. Because of the risks outlined above, we cannot, however, guarantee the security and confidentiality of e-mail or internet communication.

3. Patients must consent to the use of e-mail for confidential medical information after having been informed of the above risks. Consent to the use of e-mail includes agreement with the following conditions:

All e-mail to and from patients concerning diagnosis and/or treatment will be made a part of the protected personal information. As a part of the protected personal health information, other individuals, such as Wellness Alternatives physicians, other health care practitioners, insurance coordinators and upon written authorization other health care providers and insurers will have access to e-mail messages contained in protected personal health information.

o Wellness Alternatives may forward e-mail messages within the practice as necessary for diagnosis and treatment. Wellness Alternatives will not, however, forward the email outside the practice without the consent of the patients as required by law.

o Wellness Alternatives will endeavor to read e-mail promptly but can provide no assurance that the recipient of a particular e-mail will read the e-mail message promptly. Therefore, e-mail must not be used in a medical emergency. o It is the responsibility of the sender to determine whether the intended recipient received the e-mail and when the recipient will respond.

o Because some medical information is so sensitive that unauthorized disclosure can be very damaging, e-mail should not be used for communication concerning diagnosis or treatment of AIDS/HIV infection; other sexually transmissible or communicable diseases, such as syphilis, gonorrhea, herpes and the like; Behavioral health, Mental health or developmental disability; or alcohol and drug abuse.

o Wellness Alternatives cannot guarantee that electronic communication will be private. However, we will take reasonable steps to protect the confidentiality of the e-mail or internet communication but Wellness Alternatives is not liable for improper disclosure of confidential information not caused by its employee’s gross negligence or wanton misconduct.

o If consent is given for the use of e-mail, it is the responsibility of the patient’s to inform Wellness Alternatives of any types of information you do not want to be sent by e-mail.

o It is the responsibility of the patient to protect their password or other means of access to e-mail sent or received from Wellness Alternatives to protect their confidentiality. Wellness Alternatives is not liable for breaches of confidentiality caused by the patient.

Any further use of e-mail initiated by the patient that discuss diagnosis or treatment constitutes informed consent to the foregoing.

I understand that my consent to the use of e-mail may be withdrawn at anytime by e-mail or written communication to Wellness Alternatives.

I have read this form carefully and understand the risks and responsibilities associated with the use of e-mail.

I agree to assume all risks associated with the use of e-mail.