Email Consent Form

Burgess Pediatrics Communication Consent Preferences

Patient Name:

At Burgess Pediatrics we are able to use email to communicate with you about routine matters such as appointments, follow-up inquiries, prescriptions, certain laboratory x-ray studies as well as billing communications.

We recognize that email is not a secure communication method and should be considered as visible as a postcard. Breaches in confidentiality and failure to transmit information can occur by errors in sending, email interception, server intrusions and other events. Email is also not appropriate for real-time communication about urgent medical matters. Other communication methods available at Burgess Pediatrics include telephone calls, texting and messaging through Elation’s secure Passport, our electronic medical record program and Telehealth via Zoom video. Knowing this, please indicate your email and video preferences below.

Texts and regular emails are not HIPAA-compliant. Please select one:

I accept emails/texts with BOTH personal health information (PHI) and administrative matters. I accept emails/texts with appointment reminders, administrative matters ONLY, but NOT personal health information (PHI). Send me an invitation to Passport for PHI. I ONLY want to receive ALL emails /PHI via Elation Passport. Send me a link to sign up for Passport.

Video visits for Telehealth via Elation Zoom are HIPAA-compliant. Please select one:

I do accept video calls I do NOT accept Telehealth video calls

I/we authorize the physicians and staff at Burgess Pediatrics to communicate with us based on the choices on this form and acknowledge that email, text and video are not secure and not HIPAA compliant. I will notify Burgess Pediatrics immediately if these email addresses or my/our preferences change.

Primary Parent/Guardian Name (or, if patient is over 18, your name):

Email:

Secondary Parent/Guardian Name:

Email:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature:

Date:

Your information will be encrypted.