E-mail/Text Message Consent Form

Please correct the errors described below.

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.

Your message will be encrypted and can only be read by Comprehensive Mental Health Services.