Patient Consent

I expressly permit CARE2U, at its discretion, to communicate my PHI, via email at the e-mail address I indicated on this form.

E-MAIL RISKS AND YOUR RESPONSIBILITY

At the discretion of CARE2U and upon your agreement to the terms outlined within this consent form, CARE2U may use e-mail to communicate with you. These e-mails may contain your personal health information. If you agree to permit CARE2U to use e-mail to communicate with you, you should be aware of the following risks and/or your responsibilities:

a) As the Internet is not secure or private, unauthorized people may be able to intercept, read and possibly modify email you send or are sent by CARE2U;

b) You must protect your e-mail account, password and computer against access by unauthorized people;

c) Since e-mail can be used to spread viruses, some which cause e-mail messages to be sent to people who you do not intend to send e-mail messages to, you should install and maintain virus protection software on your PC or other personal device;

d) Since e-mails can be copied, printed and forwarded by people to whom you send emails, you should be careful regarding whom you send e-mails;

e) You shall immediately inform those individuals with whom you communicate with at CARE2U of changes in your e-mail address; and

f) You shall send e-mails only to such CARE2U e-mail addresses as instructed.

ACKNOWLEDGMENT AND AGREEMENT

CARE2U will use reasonable means to protect the privacy of the patient’s health information. However, because of the risks outlined above, CARE2U cannot guarantee that e-mail will be confidential. Additionally, CARE2U will not be liable in the event that you or anyone else inappropriately uses or accesses your e-mail. CARE2U will not be liable for improper disclosure of your health information that is not caused by CARE2U’s intentional misconduct.