Health Information Email/Text Communication Consent Form

Technological advances make communication easier in many ways. We want to increase ease and access by offering our patients/parents/legal guardians the opportunity to communicate by email or text messaging when appropriate. Using e-mail/text to discuss patient information is different in many ways. Email/Text may be used for prescription refill requests if applicable, appointment requests or other matters not requiring an immediate response. Email/Text messaging is not the perfect way to convey medical information or to discuss medical conditions. E-mail and/or text message communication has a number of possible risks that patients/parents/legal guardians should consider before using e-mail or text message. If the patient/parent/legal guardian is worried about any information being seen by other people, or if the question or problem is urgent, then other form(s) of communication such as telephone communication should be used.

Some of the possible risks of using e-mail or text messaging include, but are not limited to, the following:

Emails/Texts should not be used for Life threatening emergencies or imminent threats of harm to self or others: If a patient requires immediate assistance or has a serious or worsening condition, the patient should not rely on email. Instead the patient should call 911 for immediate assistance or go to the local emergency service provider.

E-mail/text messages can occasionally be intercepted, changed, forwarded, or used without authorization or detection.

E-mail or text messages can be used to introduce viruses into computer systems

Limit or avoid using an employer's or other third party's computer or other devices.

Inform the therapist/provider of any changes in the patient's email address or Phone's number.

Take precautions to preserve the confidentiality of emails/text, such as using screen savers and safeguarding passwords.

The privacy and security of email communication cannot be guaranteed hundred percent.

Human Error/ Unintended disclosure (typos) resulting in it being sent to many unintended recipients.

Security measures such as Employers -based systems with legal right to inspect and keep emails that pass through their system.

Back-up copy (Even after deletion of the email/text, back-up copies may exist).

Phishing Attempts or Spyware or Malware

Our providers are not responsible for information loss due to technical failures associated with the patient's email software or internet service provider.

As part of your permanent record, emails/text may be released along with the rest of the record upon your authorization or when the doctor is otherwise legally required to do so.

Messages may be seen by staff for the purpose of filing or carrying out requests (e.g., appointment scheduling).

Withdraw consent only by e-mail or written communication (Contact us immediately) if your email or phone info is no longer valid or if you wish to discontinue communication or opt out.

The patient/parent/legal guardian should not use email or text messages to discuss any subjects that the patient/parent/legal guardian feels should be kept confidential, such as sensitive medical information regarding sexually transmitted diseases, AIDS/HIV, mental health, developmental disability, or substance abuse.

Email/Text can be used as evidence in court.

Emails/text to or from the patient concerning treatment may be printed in full and made part of the patient's medical record.

We may forward emails/text internally to those involved, as necessary, for healthcare operations and other administrative handling.

We will make every effort to read and respond promptly to all emails/text from the patient, it is not guaranteed that any communication will be read and responded to within immediately. Please allow a minimum of 5 (five) business days for a response (Email should not be used for medical emergencies, urgent situations or any other time' sensitive matters).

Patient acknowledgment and agreement

I consent to the use of email/text communication for health related services and or treatment. I am responsible for informing LunaJoy Inc and Thriving Lane, LLC of any type of information that I do not want to be sent via email/text. I am responsible for protecting passwords and access to the designated email/text to ensure my confidentiality. The clinician/provider cannot be held liable if there is a breach of confidentiality caused by a breach in my account security. If I wish to discontinue emailing/texting information, I must submit written consent, or an email informing your clinician that you are withdrawing consent to email or text information. E-mails/Texts to or from the patient/parent legal guardian concerning diagnosis or treatment may be printed out and/or made part of the patient's medical record. Since they are then a part of the medical record, other individuals who are authorized to view the medical record, such as staff and billing workforce members, may also have access to those emails/text.

I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communication of email/text between LunaJoy/Thriving Lane, LLC, and consent to the conditions outlined herein, as well as any other instructions that may be required to communicate. I acknowledge the provider/therapist's right to withdraw the option of communicating through email/text without written notice. v1.3