E-mail/Text Message Consent Form

CMHS

Comprehensive Mental Health Services was founded in 1988. Since the beginning our plan has been to combine the personal attention of a private practice with the strength of a larger organization. Accordingly, we employ a broad range of clinicians, we offer a wide range of services and - within the practice - we contribute to one another's work.

Patient Name

Patient E-Mail Address

Patient Cell Phone Number

1. RISK OF USING E-MAIL/TEXT MESSAGES:

E-mail/text messages can be circulated, forwarded, and stored in numerous paper and electronic files.
E-mail/text messages can be immediately broadcast worldwide and be received by many intended and unintended recipients.
E-mail/text messages senders can easily misaddress an e-mail or cell phone number.
E-mail/text messages are easier to falsify than handwritten or signed documents.
Backup copies of e-mail/text messages may exist even after the sender or recipient has deleted his or her copy.
Employers and on-line services have a right to archive and inspect e-mails/text messages transmitted through their systems.
E-mail/text messages can be intercepted, altered, forwarded, or used without authorization or detection.
E-mail/text messages can be used as evidence in court.
E-mail can be used to introduce viruses into computer systems.

2. E-MAIL/TEXT MESSAGES ARE USED FOR:

Exchange of documents.
Scheduling.
Matters not requiring an immediate response.

3. E-MAIL/TEXT MESSAGES SHOULD NOT BE USED:

In an emergency.
If you are experiencing any desire to harm yourself or others.
If you are experiencing a severe medication reaction.
If you need an immediate response.
For any item of a clinical nature.

WHAT HAPPENS TO MY MESSAGE:

E-mails will be printed out and maintained as a permanent part of your medical record.
As part of your permanent record, they will be released along with the rest of the record upon your authorization or when the clinician is otherwise required to do so.
Messages will be seen by staff for the purposes of filing or carrying out requests (e.g. appointment scheduling).

TO COMMUNICATE BY E-MAIL/TEXT MESSAGES, THE PATIENT SHALL:

Inform provider of changes in his/her e-mail address or cell phone number.
Include his/her name in the body of the message.
Inform clinician in writing should he/she decides to cease communicating via e-mail/text.
On the subject line, include the general topic of the message, for example, prescription or appointment. (Not applicable for text messages)

PATIENT ACKNOWLEDGEMENT AND AGREEMENT: I have read and understand the information above, and had any questions answered to my satisfaction. I agree to the guidelines for e-mail communication.

Signature of Patient or Guardian

Date

Provider Name

Date

Your information will be encrypted.