PORTAL CONSENT FORM
Sussex Pulmonary and Endocrine Consultants, PA offers secure viewing and communication through its EMR vendor’s
(eClinicalworks) secure servers as a service to patients who wish to view parts of their records and communicate with our
staff and physicians.
Secure messaging can be a valuable communications tool but has certain risks. To manage these risks, we need to impose
some conditions of participation. This form is intended to show that you have been informed of these risks and the
conditions of participation, and that you accept the risks and agree to the conditions of participation. By signing below, you
confirm that you have read, understand, and agree to comply with our procedures and guidelines for using the Patient
Portal. You also agree not to hold Sussex Pulmonary and Endocrine Consultants, PA or any of their staff liable for network
infractions beyond their control.
This method of communication and viewing prevents unauthorized parties from being able to access or read messages while
they are in transmission. No transmission system is perfect, and we will do our best to maintain electronic security. However,
keeping messages secure depends on two additional factors: the secure message must reach the correct email address, and
only the correct individual (or someone authorized by that individual) must be able to get access to it.
We need you to make sure we have your correct email address and are informed if it ever changes. You also need to keep
track of who has access to your email account so that only you, or someone you authorize, can see the messages you receive
Patient Acknowledgement and Agreement
I acknowledge that I have read and fully understand this consent form and the Policies and Procedures Regarding the Patient
Portal. I understand the risks associated with online communications between my physician and me, and consent to the
conditions outlined herein. In addition, I agree to follow the instructions set forth herein and including the policies and
procedures, as well as any other instructions that my physician may impose to communicate with patients via online
communications. All my questions have been answered and I understand and concur with the information provided in the