Patient Email and Text Message Informed Consent

 

Modern Psychiatry Center, PLLC (“MPC”) and its affiliates, with which your information may be shared under HIPAA, will communicate with you by email, text message, and/or other forms of unencrypted electronic communication (together, “Electronic Messaging”) to the telephone number(s), email(s), or other locations reflected on your account. This form provides information about the purpose, risks, and conditions of Electronic Messaging.

 

How we will use Electronic Messaging:

MPC may use Electronic Messaging to communicate with you regarding a wide range of healthcare related issues, including:

  • Reminders of appointments or actions, notices about treatment options, coordination of care and other available health services;

  • How to participate in patient satisfaction surveys or how to use our secure patient portal (Healow); and

  • Information regarding insurance, billing, and account balances.

MPC may use automatic dialers or pre-recorded voice messages when it communicates with you through Electronic Messaging.

Risk of using Electronic Messaging:

Potential risks associated with Electronic Messaging include:

  • Electronic Messages can be circulated, forwarded, sent to unintended recipients, and stored electronically and/or on paper.

  • Electronic Messages may be intercepted, altered, forwarded, or used without authorization or detection.

  • Employers and online providers can inspect Electronic Messaging sent through their systems.

  • Electronic Messaging can be used as evidence in court.

 

Conditions for the use of Electronic Messaging:

MPC will use reasonable means to maintain the security and confidentiality of the messages we send. By signing below, you acknowledge your consent to the use of Electronic Messaging on the following conditions:

  • IN A MEDICAL EMERGENCY, DO NOT USE ELECTRONIC MESSAGING, CALL 911. Urgent messages should be relayed to us by using regular telephone communication.

  • Electronic Messaging may be filed into your medical record.

  • MPC is not liable for breaches of confidentiality caused by you or any third party.

  • You are solely responsible for any charges incurred under your agreement with your Electronic Messaging service provider

 

Expiration and Withdrawal of Consent:

Unless you earlier withdraw your consent, this consent will expire upon the end of your treatment relationship with MPC. You may choose to stop participating in Electronic Messaging at any time by informing MPC in writing. Withdrawing this consent will not cause you to lose any benefits or rights to which you are otherwise entitled. 

 

Patient Acknowledgement and Agreement:

I have read and fully understand the purpose, risks, and conditions associated with the use of Electronic Messaging. By utilizing the services, I consent to the use of Electronic Messaging by Modern Psychiatry Center, PLLC as stated.