CONSENT FOR STUDENT HEALTH SERVICES EMAIL COMMUNICATIONS
With this form, you authorize Student Health Services to communicate your general patient medical information to you via email. Patients must consent to Student Health Services’ (SHS) use of email for their general patient medical information. Student Health cannot communicate specific patient medical information or medical advice via email due to the insecure nature of email communications. Examples of acceptable communications include “Results are in,” “Results are normal,” or confirmation of appointments. SHS uses reasonable means to protect the security and confidentiality of email information sent and received. However, because of the risks identified below, SHS cannot guarantee the security and confidentiality of email communication, and is not liable for improper disclosure of confidential information that is not caused by SHS’ intentional misuse. SHS will not forward emails to independent third parties without the patient’s prior written consent, except as authorized or required by law. SHS will not engage in email communication that is unlawful, such as unlawfully practicing medicine across state lines. RISKS ASSOCIATED WITH EMAIL Some, but not all, of the risks with email are listed here: • Email can be immediately broadcast worldwide and received by many intended and unintended recipients; • Email senders can easily misaddress an email; • Email is easier to falsify than handwritten or signed documents; • Backup copies of email 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 emails transmitted through their systems; • Email can be intercepted, altered, forwarded, or used without authorization or detection; • Email can be used to introduce system computer viruses; and • Email can be used as evidence in court. PATIENT OBLIGATIONS WHEN CONSENTING TO EMAIL • Use email for general patient medical information only. Do not use email for medical emergencies, other time sensitive matters, or for non-general medical information. Include your name in the body of the message, and identify the category of question (nutrition, insurance, billing, etc.) in the message subject line. Include a phone number at which you can be reached. Please review your email to make sure that your question is as clear as possible; • Follow-up with SHS if you have not received a response to your email within one business week’s time; • Take precautions to preserve the confidentiality of email. Use screen savers and safeguard your computer password; • Inform the clinic of any changes to your email address; and • Withdraw consent to email patient information through hardcopy written communication to SHS. PATIENT’S CERTIFICATION OF HIS/HER CONSENT FOR STUDENT HEALTH SERVICES EMAIL COMMUNICATIONS Patient’s Last Name First Name MI Date of Birth (mm/dd/yyyy)
X
9-digit Carnegie Mellon Student Account #
(This is your SS#, or a 9-digit number starting with 999 or 700.)
X
Email address Phone #
X
X
X
I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communication of email between SHS and myself, and consent to the patient and SHS obligations herein.
X
________________________________________________________________
_
_X_______________________ ___
Date Patient signed (mm/dd/yyyy)
Patient’s signature (if not 18, an Authorized Representative must sign below)
____________________________
Authorized Representative’s signature
_________________________________
Authorized Representative’s relationship to act on behalf of Patient
______________________________
Date Auth. Rep. signed (mm/dd/yyyy)
_________________________________________________________________
Signature of SHS Staff Member witnessing this signature of Patient or Patient’s Authorized Rep.
___________________________
Date Witness signed (mm/dd/yyyy)
Witness must verify patient identity (medical id number, visit history, etc.). If form is received by FAX, verification is to be done by phone.
RETURN THIS FORM TO: Student Health Services, Carnegie Mellon, 1060 Morewood Ave, Pittsburgh, PA 15213 FAX: 412 268 6357 This form cannot be emailed. Questions can be directed to: 412 268 2157