Online Communications Informed Consent
For Online Communications with: Miguel Flores and Associates, P.A.
You agree to take steps to keep your online communications to and from me
- Do not store messages on your employer-provided
computer; otherwise, personal information could be accessible or owned by
- Use screen savers or close your messages instead of
leaving your messages on the screen for passersby to read and keep your
password safe and private.
- Do not allow other individuals or other third party
access to the computer(s) upon which you store medical messages or other
personal medical information.
- If you have or learn of any personal email addresses
that I use, you will not use them for medical communications. Standard
email lacks security and privacy features and may expose medical
communications to employers or other unintended third parties.
- Withdrawal of this Informed Consent must be done by
written online communications or in writing to my office.
- Confirm that your name and other personal information
in the message is correct
- Review the message before sending it to make sure
that it is clear and that all relevant information is included.
your contact information on the network as soon as it changes including and
changes to your regularly used email address. I do not use your standard email
account for security reasons, but notifications are sent to your standard email
address when a message has been sent to you and is waiting for you in your
My office may charge for certain online communications. You will be informed in
advance when/if these charges apply and you will be responsible for payment of
these charges if you accept and use any fee-based service. You may choose to
contact your insurance carrier to determine if they cover online
The following agreements and procedures relate online communications:
- My office will print out a copy of all medically
important online communication and include it in your medical record. This
means that appropriate members of my staff will have access to these communications
as part of our medical records keeping, treatment and billing.
- You should print or store (on a computer or storage
devise owned and controlled by you) a copy of all online communications
that are important to you.
- I will not forward online communications with you to
third parties except as authorized or required by law.
- You agree to follow the procedures that I implement
that will allow me to verify your identity in connection with online
communications and you acknowledge that failure to comply with these
procedures may terminate our online communications.
- Online communications will be used only for limited
purposes. It cannot be used for emergencies or time-sensitive matters. It
should be used with caution. It should not be used to communicate highly
sensitive medical information, such as treatment for or information
related to HIV/AIDS, sexually transmitted diseases, or addiction treatment
(alcohol, drug dependence, etc.) If there is other information that you
don't want transmitted via online communications, you must tell me.
- I will make every attempt to respond within the
timeframe I have designated. However, there may be times when this is not
feasible, and you understand and agree to accept variations in response
times and use other forms of communications with my office and me if
online responses are not satisfactory to you. Please note that online
communications should never be used emergency communications or urgent
requests. These should occur via telephone or using existing emergency
- While I will take reasonable precautions to protect
your information, I am not liable for improper disclosure of confidential
information unless it was caused by my intentional misconduct.
- Follow-up is your responsibility. You are responsible
for scheduling any necessary appointments and for determining if an
unanswered online communications wasn't received.
- You are responsible for taking steps to protect
yourself from unauthorized use of online communications, such as keeping your
password confidential. I am not responsible for breaches of
confidentiality caused by you or an independent third party.
- I will not engage in any illegal online
communication, including illegally practicing medicine across state lines.
The following pertains to access to and use of online communications:
- Online communications does not decrease or diminish
any other ways in which you can communicate or see me. It is an additional
option and not a replacement. You are encouraged to contact my office via
telephone, mail or in person, as always, if you have any questions or
- I alone will decide which medical topics are
appropriate for online communications and with whom I communicate online.
- I may stop providing online communications with you
or change my online services provided at any time without prior
notification to you.
All medical communications carry some level of risk. While the likelihood of
risks associated with the use of online communications, particularly in a
secure environment, are substantially reduced, they are nonetheless real and
very important to understand. It is very important that you consider these
risks each time you plan to communicate with me, and communicate in such a
fashion as to mitigate the potential for any of these risks. These risks
include, but are not limited to:
- Online communication may travel much further than you
planned. It is easier for online communications to be forwarded,
intercepted, or even changed without your knowledge.
- Online communications is easier to falsify than
handwritten or signed hard copies. A dishonest person could attempt to
impersonate you to try to get your medical records.
- It is harder to get rid of an online communications.
Backup copies may exist on a computer or in cyberspace, even after both of
us have deleted our copies.
- Online communication is not private simply because it
relates to your own medical information. I use a secure network to avoid
using standard email or email systems provided by employers. Employers and
online services have a right to inspect and keep online communications
transmitted through their system. Some employers also use video-cams and
- Online communications are also admissible as evidence
- Online communications may disrupt or damage your
computer if a computer virus is attached.
I acknowledge that I have read and fully understand this consent form. I
understand the risks associated with the communication of online communications
between my physician and me, and consent to the conditions outlined herein. In
addition, I agree to the instructions outlined herein, as well as any other
instructions that my physician may impose to communicate with patients via
online communications. I have had a chance to ask any questions that I had and
to receive answers. I have been proactive about asking questions related to
this consent agreement. My questions have been answered and I understand and
concur with the information provided in the answers.
reading if you have any questions please contact Georgia Witt at 936-760-2300
or 936-441-2300 for your answers. After
any questions are answered please copy the remainder of this page and paste
into an email to us. You will be asked
to sign your email when you next come into the clinic.
acknowledge that I have read and fully understand Online
Communications Informed Consent
form. I understand
the risks associated with the communication of online communications between my
physician and me, and consent to the conditions outlined herein. In addition, I
agree to the instructions outlined herein, as well as any other instructions
that my physician may impose to communicate with patients via online
communications. I have had a chance to ask any questions that I had and to
receive answers. I have been proactive about asking questions related to this
consent agreement. My questions have been answered and I understand and concur
with the information provided in the answers.