Informed Consent Regarding Email Or The Internet Use Of Protected Personal Information

 The offices of Jane Q. Lawyer, P.C. hereby provides Clients with these warnings about communications via internet or email:

Transmitting confidential health information by e-mail has a number of risks, both general and specific, that should be considered before using e-mail.

1. Risks:
   1. General e-mail risks are the following: e-mail can be immediately broadcast worldwide and be received by many intended and unintended recipients; recipients can forward e-mail messages to other recipients without the original sender(s) permission or knowledge; users can easily misaddress an e-mail; e-mail is easier to falsify than handwritten or signed documents; backup copies of e-mail may exist even after the sender or the recipient has deleted his/her copy.
   2. Specific e-mail risks are the following: e-mail containing confidential information must be protected; all individuals who have access to Client’s email could have access to such confidential information; Clients who send or receive e-mail from their place of employment risk having their employer read their e-mail.
2. It is the policy of this office that all e-mail messages sent or received which concern private information or confidences be a part of that Client’s protected personal information and will treat such e-mail messages or internet communications with the same degree of confidentiality as afforded other portions of the protected confidences, including personal health information. This office will use reasonable means to protect the security and confidentiality of e-mail or internet communication. Because of the risks outlined above, we cannot, however, guarantee the security and confidentiality of e-mail or internet communication.
3. Clients must consent to the use of e-mail for confidential medical information after having been informed of the above risks. Consent to the use of e-mail includes agreement with the following conditions:
   
   1. All e-mails to or from Clients concerning or containing confidential information, advice or other protected confidences will be made a part of the Clients file. As part of the protected confidences and personal health information, other individuals whom you authorize this office to consult with, will have access to e-mail messages containing such information you authorize us to deliver.
   2. This office may forward e-mail messages to authorized parties as necessary for assistance, consultation, diagnosis and treatment. Our office will not, however, forward the e-mail outside the practice without the consent of the Client as required by law.
   3. Our office will endeavor to read e-mail promptly but can provide no assurance that the recipient of a particular e-mail will read the e-mail message promptly. Therefore, e-mail must not be used in an emergency, and never for a medical emergency.
   4. It is the responsibility of the sender to determine whether the intended recipient received the e-mail and when the recipient will respond.
   5. Because some information, including medical information, is so sensitive that unauthorized discloser can be very damaging, e-mail should not be used for communications concerning discussions of culpability, negligence, or diagnosis or treatment of AIDS/HIV infection; other sexually transmissible or communicable diseases, such as syphilis, gonorrhea, herpes, and the like; nor to discuss behavioral health, mental health or developmental disability; or alcohol and drug abuse.
   6. Our office cannot guarantee that electronic communications will be private. However, we will take reasonable steps to protect the confidentiality of the e-mail or internet communication but our office is not liable for improper disclosure of confidential information not caused by its employees from negligence or wanton misconduct.
   7. If consent is given for the use e-mail, it is the responsibility of the Client to inform our office of any types of information you do not want to be sent by e-mail. It is the responsibility of the Client to protect their password or other means of access to e-mail sent or received from our office to protect confidentiality. Our office is not liable for breaches of confidentiality caused by the Client.

Any further use of e-mail initiated by the Client that discusses attorney-client privileged information, private sensitive information or medical records, including diagnosis or treatment constitutes informed consent to the foregoing.

I understand that my consent to the use of e-mail may be withdrawn at any time by e-mail or written communication to the offices of Jane Q. Attorney.

I have read this form carefully and understand the risks and responsibilities associated with the use of e­mail.

I agree to assume all risks associated with the use of e-mail.

Client Name:_______________ Date:_______________

Signature:_____________________________________