Fillable Patient Portal User Agreement and Consent

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Patient Portal User Agreement and Consent

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Please DO NOT use Patient Portal to communicate with your Practice for urgent or emergency medical issues. If
you are experiencing an urgent medical need, please contact us by phone.
For emergencies call 911.
Patient Portal User Agreement and Consent
Effective: August 10, 2012
The Patient Portal (defined below) is owned and operated by the practice to which you are seeking to online access (the
“Practice”). The Practice has adopted this user agreement (“User Agreement” or “Agreement”) to make you aware of the
terms and conditions of your use of the Patient Portal and any derivative websites of the Patient Portal (collectively, the
“Patient Portal”). In the event that you purport to be the agent of, represent, or otherwise act on behalf of any other person,
references to “you,” “your” or “User” shall include such entity or person in addition to such representative, and your
acceptance of this Agreement shall constitute acceptance on behalf of such person.
The Practice uses reasonable efforts to maintain the Patient Portal, but the Practice is not responsible for any defects or
failures associated with the Patient Portal, any part thereof or any damages (such as lost profits or other consequential
damages) that may result from any such defects or failures. The Patient Portal may be inaccessible or inoperable for any
reason, including, without limitation: (a) equipment malfunctions, (b) periodic maintenance procedures or repairs which
the Practice may undertake from time to time or (c) causes beyond the control of the Practice or which are not foreseeable
by the Practice. In addition, the Practice makes no guarantees as to the web sites and information located worldwide
throughout the Internet that you may access as a result of your use of the Patient Portal, including as to the accuracy,
content, or quality of any such sites and information or the privacy practices of any such site. The Practice is not a backup
service for storing data you submit to the Patient Portal, and the Practice shall have no liability regarding any loss of such
data. You are solely responsible for creating backups of any data you submit using the Patient Portal.
The Patient Portal is a secure website that allows you to use a computer to interact with medical information via the
internet. The Patient Portal also allows you to communicate with the Practice via secure messaging. Please note that all
communication via the Patient Portal will be included in your permanent patient record.
Responsibilities, Risks and Benefits:
The Patient Portal is provided as a convenience to you at no cost and is only available in English at this time. We
do not sell or give away any private information, including email addresses. We reserve the right to suspend or
terminate the Patient Portal access at any time and for any reason.
All messages sent to you will be electronically secure. Messages and emails from you to any staff member must
be sent through the Patient Portal for security and confidentiality reasons.
The Patient Portal messages will be handled by our staff in a manner similar to how phone communication is
handled.
Although we strive to reply to Patient Portal messages within one business day, we cannot guarantee that we will
be able to address your messages in that timeframe. We encourage you to use the Patient Portal at any time but
understand that we can only reply to messages during our office hours, excluding holidays recognized by the
Practice. If you do not receive a response within two business days, please feel free to call our office.
You are responsible to provide us with your correct email address and inform us immediately of any change. You
are also responsible for the protection of your login information and password.
Please understand that all electronic communications carry some degree of risk, even in a secured environment. Even
with all due precautions, online communications may be intercepted, forwarded or changed without a patient’s or the
healthcare provider’s knowledge. By using or accessing the Patient Portal, you expressly accept these risks. Note that it
is easier for a
patient’s identity to be stolen or for someone to try to impersonate a patient via online communication.
Online communications are admissible as evidence in court just as medical records are in the event the physician-
patient privilege is waived or if a court orders disclosure.
Online communications may disrupt or damage a computer if a computer virus is transmitted via an attached file,
hyperlink or other method. You assume liability for such disruptions or damages caused by such transmissions.
Responses to online communications are limited by the information provided and your question may necessitate
a follow-up phone call or a request to meet with you in person to gain further information.
________________________________________________________________ ________________ ________________
Electronic communications will be viewed by not only the physician, but the staff members assigned to handle
such communications and any other provider covering for the patient’s physician if the patient’s physician is
unavailable to respond.
Applicable law may allow a health care professional to determine that a minor patient is “mature” to keep a
portion of the minor’s medical information confidential. If the minor patient is determined “mature” by his or her
physician, all Patient Portal communication will be with the minor directly and a new consent form with the
minor’s email address will be required.
Applicable law may also permit confidential communication with a minor patient in regards to treatment and
reporting of sexually transmitted diseases to the minor and communications with pregnant minors in regards to
questions about the health of her fetus. In these situations, all Patient Portal communications will be directly with
the minor and a new consent form with the minor’s email address will be required.
The Practice will keep a copy of all medically important online communications in your medical record secure
pursuant to applicable federal and state laws and regulations. Print or store in a secure place (on a computer or
storage device owned and controlled by you) a copy of all online communications that are important to you.
The Practice will not forward online communications with you to third parties except as authorized or required
by law.
Please note that online communications should never be used for emergency communications or urgent requests.
These should occur via telephone or using existing emergency communications tools as noted above.
Follow-up is solely your responsibility. You are responsible for scheduling any necessary appointments and for
determining if an online communication did not receive a response.
You are responsible for taking steps to protect yourself from unauthorized use of online communications, such as
keeping your password confidential. The Practice is not responsible for breaches of confidentiality caused by you
or an independent third-party.
Guidelines for Safe Online Communications
Take steps to keep your online communications to and from the Practice confidential, including:
Do not store messages on your employer-provided devices (e.g. computer, cell phone, tablet, etc.); otherwise
personal information could be accessible or owned by your employer.
Use a screen saver 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 third parties access to the devices(s) upon which you store medical
communications.
Keep your login and password information secure and confidential.
Do not use email for medical communications. Standard email lacks the necessary security and privacy features
and may expose medical communications to employers or other unintended third-parties.
Access to Online Communications
The following pertains to access to and use of online communications:
Online communications do not decrease or diminish any of the other ways in which you can communicate with
your provider. It is an additional option and not a replacement.
The Practice may stop providing online communications with you or change the services provided online at any
time without prior notification to you.
I acknowledge that I have read and fully understand the Patient Portal User Agreement and Consent. I have read and
understand the responsibilities and benefits of the Patient Portal and understand the risks associated with online
communications between me and my physician’s office. I consent to the conditions outlined and I agree to keep my
password confidential and notify the office if my email address changes at any time. 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 Agreement. All of
my questions have been answered and I understand and concur with the information.
Print Patient Name: ________________________________________________ Date of Birth ______________________
Email address: ____________________________________________________
Signature Relationship Date
I am over the age of 18 and have sole responsibility of my medical care
□ Yes
□ No (We do not offer the Patient Portal to minors or those patients which do not make their own medical
decisions at this time. We apologize for the inconvenience.)
I choose not to participate in Patient Portal at this time because:
□ I do not have an E-mail address
□ I do not wish to share my E-mail address
□ English is not my preferred language
□ Other
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Patient Portal User Agreement and Consent

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Completed 3 February 2022

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