Email and Text Messaging Consent


TERMS AND CONDITIONS FOR THE USE OF E-MAIL AND TEXT MESSAGING COMMUNICATIONS

 

I agree to the following terms and conditions for the use of e-mail and text messaging (and other rules that may be added and provided to me from time to time):

  • All e-mail and text message communication will be included in the patient’s medical record.
  • White House Clinics cannot guarantee that any e-mail or text message will be read and responded to within a specific timeframe. The typical timeframe for response is less than one business day, however it may take 1 week or longer if the person to whom the e-mail/text message is sent is away or if the email system/mobile network is not working. Therefore, e-mail and text messaging should not be used for medical or mental health emergencies or other matters that require an urgent response.
  • If the patient has not received a response within a reasonable time period, it is the patient’s
    responsibility to call White House Clinics in order to determine whether the intended recipient receivedthe e-mail and when the recipient will respond.
  • The patient or parent/guardian should not use e-mail or text messages to discuss any subjects that the patient or parent/guardian feels should be kept confidential, including any sensitive medical information regarding sexually transmitted diseases, AIDS/HIV, mental health, developmental disability or substance use.
  • Where applicable, you may see a charge from your insurance for the time necessary for the physician to respond to the electronic communication.
  • It is the patient’s responsibility to protect the mobile device from being used or viewed by others. The patient or parent/guardian is responsible for protecting his/her password or other means of access to e-mail or text messaging. White House Clinics is not liable for information read by other people.
  • It is the responsibility of the patient/guardian to inform White House Clinics of any change in e-mail or text messaging addresses.
  • A White House Clinics provider, in his or her own discretion, may determine that a telephone call or office visit is more appropriate for communication with the patient. If a White House Clinic’s provider determines that an office visit is necessary of if the patient wants an office visit, it is the patient’s responsibility to call to schedule an appointment.
  • Standard text message rates may apply.
  • Consent to Electronic Communications may be withdrawn by e-mail or written communication to White House Clinics.

Best Practice Utilization for E-mail Communication:

  • When initiating e-mail communication include the patient’s full name and date of birth in the
    body of the first e-mail message and not in the subject line to ensure that White House Clinics
    staff are in communication with the correct person.
  • Include the category for the communication in the e-mail’s subject line, (e.g. “I have a laboratory test question”) to ensure that the electronic communication can be forwarded to the
    appropriate person instance.

E-MAIL AND TEXT MESSAGING CONSENT FORM

I hereby request and authorize White House Clinics to use e-mail and text messaging to communicate with me. I understand that such electronic communications may include protected health information and expose my information to various risk including, but not limited to the following:

• E-mails and text messages are sent and received using a network/platform that is not secure;
• E-mails and text messages can be intercepted, viewed, changed, forwarded, or used without
authorization or detection;
• E-mail or text message senders can easily misaddress the message; information can then be received by unintended parties;
• E-mail information or text messages can be sent on to other people, stored on a computer, or printed out on paper for storage;
• E-mail or text message information may be kept on computers or electronic devices such as mobile phones even after the sender or the recipient believes they deleted his or her copy;
• Employer and online services have a right to archive (store) and look at e-mails/text messages
transmitted through their systems. Some, but not all, employers store e-mail/text messages indefinitely;
• E-mails or text messages can be used to introduce viruses into computer systems;
• E-mails or text messages can be used as evidence in court;
• E-mails or text messages could be viewed by others in possession of the mobile device.

I understand that White House Clinics cannot guarantee the security and privacy of e-mail and text message communications and I agree not to hold White House Clinics liable for improper use and/or disclosure of my protected health information transmitted through e-mail or text message.

I have read and agree to the White House Clinics Terms and Conditions for the Use of E-mail and Text
Messaging (and other rules that may be added and provided to me from time to time).

I understand text message charges from my cellular telephone service provider may apply.

I agree to keep White House Clinics informed of my most-current mobile number at all times or if the number is no longer in my possession.

I acknowledge that I have read and understand the information contained in this document. I understand the risks associated with e-mail and text messaging communications and consent to the use of e-mail and/or text messaging. I have also read and understand the Terms and Conditions of Use for E-mail and Text Messaging Communications. I agree to comply with such Terms and Conditions and any other instructions White House Clinics may impose regarding e-mail and text messaging communications.

Patient Name:

Patient DOB:

Patient Email:

 

Date Signed:

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Signature Certificate
Document name: Email and Text Messaging Consent
lock iconUnique Document ID: 8df3e808537950a1eb59c05791de1aae797cb7c9
Timestamp Audit
June 1, 2020 3:32 pm EDTEmail and Text Messaging Consent Uploaded by White House Clinics - Consent.forms@whitehouseclinics.com IP 184.170.166.105
June 2, 2020 2:34 pm EDTWhite House Clinics - Consent.forms@whitehouseclinics.com added by White House Clinics - Consent.forms@whitehouseclinics.com as a CC'd Recipient Ip: 107.10.167.18
June 2, 2020 2:34 pm EDTBlue Million - q@bluemillion.com added by White House Clinics - Consent.forms@whitehouseclinics.com as a CC'd Recipient Ip: 107.10.167.18
June 4, 2020 11:38 am EDTWhite House Clinics - Consent.forms@whitehouseclinics.com added by White House Clinics - Consent.forms@whitehouseclinics.com as a CC'd Recipient Ip: 184.170.166.105
June 4, 2020 11:38 am EDTBlue Million - q@bluemillion.com added by White House Clinics - Consent.forms@whitehouseclinics.com as a CC'd Recipient Ip: 184.170.166.105
June 4, 2020 11:54 am EDTWhite House Clinics - Consent.forms@whitehouseclinics.com added by White House Clinics - Consent.forms@whitehouseclinics.com as a CC'd Recipient Ip: 184.170.166.105
June 4, 2020 11:54 am EDTBlue Million - q@bluemillion.com added by White House Clinics - Consent.forms@whitehouseclinics.com as a CC'd Recipient Ip: 184.170.166.105
June 4, 2020 12:01 pm EDTWhite House Clinics - Consent.forms@whitehouseclinics.com added by White House Clinics - Consent.forms@whitehouseclinics.com as a CC'd Recipient Ip: 184.170.166.105
June 4, 2020 12:01 pm EDTBlue Million - q@bluemillion.com added by White House Clinics - Consent.forms@whitehouseclinics.com as a CC'd Recipient Ip: 184.170.166.105
June 4, 2020 12:06 pm EDTWhite House Clinics - Consent.forms@whitehouseclinics.com added by White House Clinics - Consent.forms@whitehouseclinics.com as a CC'd Recipient Ip: 184.170.166.105
June 4, 2020 12:06 pm EDTBlue Million - q@bluemillion.com added by White House Clinics - Consent.forms@whitehouseclinics.com as a CC'd Recipient Ip: 184.170.166.105
June 4, 2020 12:30 pm EDTWhite House Clinics - Consent.forms@whitehouseclinics.com added by White House Clinics - Consent.forms@whitehouseclinics.com as a CC'd Recipient Ip: 184.170.166.105
June 4, 2020 12:30 pm EDTBlue Million - q@bluemillion.com added by White House Clinics - Consent.forms@whitehouseclinics.com as a CC'd Recipient Ip: 184.170.166.105
June 4, 2020 12:32 pm EDTWhite House Clinics - Consent.forms@whitehouseclinics.com added by White House Clinics - Consent.forms@whitehouseclinics.com as a CC'd Recipient Ip: 184.170.166.105
June 4, 2020 12:32 pm EDTBlue Million - q@bluemillion.com added by White House Clinics - Consent.forms@whitehouseclinics.com as a CC'd Recipient Ip: 184.170.166.105
June 4, 2020 12:38 pm EDTWhite House Clinics - Consent.forms@whitehouseclinics.com added by White House Clinics - Consent.forms@whitehouseclinics.com as a CC'd Recipient Ip: 184.170.166.105
June 4, 2020 12:38 pm EDTBlue Million - q@bluemillion.com added by White House Clinics - Consent.forms@whitehouseclinics.com as a CC'd Recipient Ip: 184.170.166.105