Fillable Urology Partners Patient Portal Agreement And Consent (Urology Partners)

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Urology Partners Patient Portal Agreement And Consent (Urology Partners)

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Urology Partners Patient Portal
Agreement And Consent
Bryan Allen, MD
Sean Castellucci, DO
Edward Herrman, MD
Ricardo D. Gonzalez, MD
G. Austin Hill, MD
Alan K. Miller, MD, FACS
Mark Weintraub, MD
Mitchell Yadven, MD
Please DO NOT use Patient portal to communicate with Urology Partners
for urgent or emergency medical issues. If you are experiencing an urgent
medical need, please contact us by telephone at 941.792.0340.
For emergencies call 911.
Effective: September 4, 2018
The Patient Portal (as defined below) is operated by Urology Partners
(herein the “Practice”) to which you are seeking to access online. The
Practice has adopted this User Agreement (herein “Agreement”) to make you
aware of the terms and conditions of your use of the Patient Portal
(herein “Portal”) and any derivative websites of the Portal. In the event that you
purport to be the agent of, representative of, or otherwise act on behalf of any
other persons, 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 full understanding and acceptance.
The Practice uses reasonable efforts to maintain the Portal, but the Practice is not
responsible for any defects or failures associated with the Portal, any part thereof or any damages (such as lost
profits or other consequential damages) that may results from any such defects or failures. The Portal may be
inaccessible or inoperable for any reason, including and without limitation to: (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 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 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 Portal.
The Portal is a secure website that allows you to use a computer to interact with medical information via the
internet. The portal also allows you to communicate with the Practice via secure messaging. Please note that all
communication via the Portal will be included in your permanent patient record.
Responsibilities, Risks and Benefits:
The Portal is provided as a convenience to you at no cost. We do not sell or give away any private information,
including email addresses. We reserve the right to suspend or terminate the Portal access at any time and for
any reason(s).
All message sent to you will be electronically secure. Messages and emails from you to any staff member must
be sent through the Portal for security and confidentiality purposes.
The Portal messages will be handled by our staff in a manner similar to how phone communication is handled.
Although we strive to reply to 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 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 the
patient’s or the healthcare provider’s knowledge or consent. By using or accessing the 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 questions may necessitate
a follow-up phone call or a request to meet with you in person to gain further information. The diagnosis or
treatment of any medical concerns will not be done via the Portal or over the Phone at any time.
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.
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 methods as noted above.
Follow-up is solely your responsibility. You are responsible for scheduling any necessary appointments and online
communication if you have not received 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 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.
Access to Online Medical Information
The Portal allows for certain medical information to be reviewed by you as allowed by the Practice. Information
published to the Portal is done so at the discretion of your provider and the Practice and some information may
not be published to the Portal prior to review with you in the office. Information published to the Portal includes,
but is not limited to:
Medications, allergies, surgical history, visit summaries and some laboratory and diagnostic results. All of these
items must be individually released to the Portal by the Practice.
Acknowledgement
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 have ad 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.
_________________________________________ ___________
Signature of Patient/Person Legally Responsible Date
_________________________________________ ___________
Print Name of Patient/Person Legally Responsible Date
_____________________________________________
Email Address of Patient/Person Legally Responsible
_________________________________________ ___________
Name of Patient and Relationship to Patient DOB of Patient
(if signed by Person Legally Responsible)
I am over the age of 18 and have sole responsibility of my medical care:
☐ Yes
☐ No
I choose not to participate in the Portal at this time because:
☐ I do not have an email address ☐ I do not wish to share my email address
☐ Other
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Urology Partners Patient Portal Agreement And Consent (Urology Partners)

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Completed 2 May 2021

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