Email Informed Consent Form

Email Informed Consent Form


Faith Pediatric Rehabilitation provides patients the opportunity to communicate with their physicians, other health care providers, and administrative services by email. Transmitting confidential patient information by email, however, has a number of risks, both general and specific, that patients should consider before using email.

Risk Factors

·     Among general email risks are the following:

o     Email can be immediately broadcast worldwide and be received by many intended and unintended recipients.

o     Recipients can forward email messages to other recipients without the original sender’s permission or knowledge.

o     Users can easily misaddress an email.

o     Email is easier to falsify than handwritten or signed documents.

o     Backup copies of email may exist even after the sender or the recipient has deleted his or her copy.

·     Among specific patient email risks are the following:

o     Email containing information pertaining to a patient’s diagnosis and/or treatment must be included in the patient’s medical records. Thus, all individuals who have access to the medical record will have access to the email messages.

o     Employees do not have an expectation of privacy in email that they send or receive at their place of employment. Thus, patients who send or receive email from their place of employment risk having their employer read their email.

o     If employers or others, such as insurance companies, read an employee’s email and learn of medical treatment, particularly mental health, sexually transmitted diseases, or alcohol and drug abuse information, they may discriminate against the employee/patient. For example, they may fire the employee, not promote the employee, deny insurance coverage, and the like. In addition, the employee could suffer social stigma from the disclosure of such information.

o     Patients have no way of anticipating how soon Faith Pediatric Rehabilitation and its employees and agent will respond to a particular email message. Although Faith Pediatric Rehabilitation and its employees and agents will endeavor to read and respond to email promptly, Faith Pediatric Rehabilitation cannot guarantee that any particular email message will be read and responded to within any particular period of time. Physicians, nurses, and other health care workers rarely have time during rounds, surgery, consultations, appointments, staff meetings, meetings away from the facility, and meetings with patients and their families to continually monitor whether they have received email. Thus, patients should not use email in a medical emergency.

Conditions for the Use of Email

·     It is the policy of Faith Pediatric Rehabilitation that Faith Pediatric Rehabilitation will make all email messages sent or received that concern the diagnosis or treatment of a patient part of that patient’s medical record and will treat such email messages with the same degree of confidentiality as afforded other portions of the medical record. Faith Pediatric Rehabilitation will use reasonable means to protect the security and confidentiality of email information. Because of the risks outlined above, Faith Pediatric Rehabilitation cannot, however, guarantee the security and confidentiality of email communication.

·     Thus, patients must consent to the use of email for confidential medical information after having been informed of the above risks. Consent to the use of email includes agreement with the following conditions:

o     All emails to or from the patient concerning diagnosis and/or treatment will be made a part of the patient’s medical record. As a part of the medical record, other individuals, such as other physicians, nurses, physical therapists, patient accounts personnel, and the like, and other entities, such as other health care providers and insurers, will have access to email messages contained in medical records.

o     Faith Pediatric Rehabilitation may forward email messages within the facility as necessary for diagnosis, treatment, and reimbursement. Faith Pediatric Rehabilitation will not, however, forward the email outside the facility without the consent of the patient or as required by law.

o     If the patient sends an email to Faith Pediatric Rehabilitation, one of its physicians, another health care provider, or an administrative department, Faith Pediatric Rehabilitation will endeavor to read the email promptly and to respond promptly, if warranted. However, Faith Pediatric Rehabilitation can provide no assurance that the recipient of a particular email will read the email message promptly. Because Faith Pediatric Rehabilitation cannot assure patients that recipients will read email messages promptly, patients must not use email in a medical emergency.

o     If a patient’s email requires or invites a response, and the recipient does not respond within a reasonable time, the patient is responsible for following up to determine whether the intended recipient received the email and when the recipient will respond.

o     Because some medical information is so sensitive that unauthorized disclosure can be very damaging, patients should not use email for communications concerning diagnosis or treatment of AIDS/HIV infection; other sexually transmissible or communicable diseases, such as syphilis, gonorrhea, herpes, and the like; mental health or developmental disability; or alcohol and drug abuse.

o     Because employees do not have a right of privacy in their employer’s email system, patients should not use their employer’s email system to transmit or receive confidential medical information.

o     Faith Pediatric Rehabilitation cannot guarantee that electronic communications will be private. Faith Pediatric Rehabilitation will take reasonable steps to protect the confidentiality of patient email, but Faith Pediatric Rehabilitation is not liable for improper disclosure of confidential information not caused by Faith Pediatric Rehabilitation’s gross negligence or wanton misconduct.

o     If the patient consents to the use of email, the patient is responsible for informing Faith Pediatric Rehabilitation of any types of information that the patient does not want to be sent by email other than those set out above.

o     Patient is responsible for protecting patient’s password or other means of access to email sent or received from Faith Pediatric Rehabilitation to protect confidentiality. Faith Pediatric Rehabilitation is not liable for breaches of confidentiality caused by patient.

o     Any further use of email by the patient that discusses diagnosis or treatment by the patient constitutes informed consent to the foregoing.You may withdraw consent to the use of email at any time by email or written communication to Faith Pediatric Rehabilitation, attention: Director of Health Information.

I have read the above risk factors and conditions for the use of email, and I hereby consent to the use of email for communications to and from Faith Pediatric Rehabilitation regarding my medical treatment.


Parent Signature:________________________________       Date:____________________


Notice of Information Practices

Understanding Your Child’s Health Record Information

Each time that your child visit’s a hospital, a physician, or another health care provider, the provider makes a record of your visit. Typically, this record contains your health history, current symptoms, examination and test results, diagnoses, treatment, and plan for future care or treatment. This information, often referred to as your medical record, serves as the following:

·     Basis for planning your care and treatment.

·     Means of communication among the many health professionals who contribute to your care.

·     Legal document describing the care that you received.

·     Means by which you or a third-party payer can verify that you actually received the services billed for.

·     Tool in medical education.

·     Source of information for public health officials charged with improving the health of the regions they serve.

·     Tool to assess the appropriateness and quality of care that you received.

·     Tool to improve the quality of health care and achieve better patient outcomes.

Understanding what is in your health records and how your health information is used helps you to—

·     Ensure its accuracy and completeness.

·     Understand who, what, where, why, and how others may access your health information.

·     Make informed decisions about authorizing disclosure to others.

·     Better understand the health information rights detailed below.

Your Rights under the Federal Privacy Standard

Although your health records are the physical property of the health care provider who completed the records, you have the following rights with regard to the information contained therein:

·     Request restriction on uses and disclosures of your health information for treatment, payment, and health care operations. “Health care operations” consist of activities that are necessary to carry out the operations of the provider, such as quality assurance and peer review. The right to request restriction does not extend to uses or disclosures permitted or required under the following sections of the federal privacy regulations: § 164.502(a)(2)(i) (disclosures to you), § 164.510(a) (for facility directories, but note that you have the right to object to such uses), or § 164.512 (uses and disclosures not requiring a consent or an authorization). The latter uses and disclosures include, for example, those required by law, such as mandatory communicable disease reporting. In those cases, you do not have a right to request restriction. The consent to use and disclose your individually identifiable health information provides the ability to request restriction. We do not, however, have to agree to the restriction, except in the situation explained below. If we do, we will adhere to it unless you request otherwise or we give you advance notice. You may also ask us to communicate with you by alternate means, and if the method of communication is reasonable, we must grant the alternate communication request. You may request restriction or alternate communications on the consent form for treatment, payment, and health care operations. If, however, you request restriction on a disclosure to a health plan for purposes of payment or health care operations (not for treatment), we must grant the request if the health information pertains solely to an item or a service for which we have been paid in full.

·     Obtain a copy of this notice of information practices. Although we have posted a copy in prominent locations throughout the facility and on our website, you have a right to a hard copy upon request.

·     Inspect and copy your health information upon request. Again, this right is not absolute. In certain situations, such as if access would cause harm, we can deny access. You do not have a right of access to the following:

o     Psychotherapy notes. Such notes consist of those notes that are recorded in any medium by a health care provider who is a mental health professional documenting or analyzing a conversation during a private, group, joint, or family counseling session and that are separated from the rest of your medical record.

o     Information compiled in reasonable anticipation of or for use in civil, criminal, or administrative actions or proceedings.

o     Protected health information (“PHI”) that is subject to the Clinical Laboratory Improvement Amendments of 1988 (“CLIA”), 42 U.S.C. § 263a, to the extent that giving you access would be prohibited by law.

o     Information that was obtained from someone other than a health care provider under a promise of confidentiality and the requested access would be reasonably likely to reveal the source of the information.

In other situations, we may deny you access, but if we do, we must provide you a review of our decision denying access. These “reviewable” grounds for denial include the following:

o     A licensed health care professional, such as your attending physician, has determined, in the exercise of professional judgment, that the access is reasonably likely to endanger the life or physical safety of yourself or another person.

o     PHI makes reference to another person (other than a health care provider) and a licensed health care provider has determined, in the exercise of professional judgment, that the access is reasonably likely to cause substantial harm to such other person.

o     The request is made by your personal representative and a licensed health care professional has determined, in the exercise of professional judgment, that giving access to such personal representative is reasonably likely to cause substantial harm to you or another person.

For these reviewable grounds, another licensed professional must review the decision of the provider denying access within 60 days. If we deny you access, we will explain why and what your rights are, including how to seek review. If we grant access, we will tell you what, if anything, you have to do to get access. We reserve the right to charge a reasonable, cost-based fee for making copies.

·     Request amendment/correction of your health information. We do not have to grant the request if the following conditions exist:

o     We did not create the record. If, as in the case of a consultation report from another provider, we did not create the record, we cannot know whether it is accurate or not. Thus, in such cases, you must seek amendment/correction from the party creating the record. If the party amends or corrects the record, we will put the corrected record into our records.

o     The records are not available to you as discussed immediately above.

o     The record is accurate and complete.

If we deny your request for amendment/correction, we will notify you why, how you can attach a statement of disagreement to your records (which we may rebut), and how you can complain. If we grant the request, we will make the correction and distribute the correction to those who need it and those whom you identify to us that you want to receive the corrected information.

·     Obtain an accounting of nonroutine uses and disclosures, those other than for treatment, payment, and health care operations until a date that the federal Department of Health and Human Services will set after January 1, 2011. After that date, we will have to provide an accounting to you upon request for uses and disclosures for treatment, payment, and health care operations. We do not need to provide an accounting for the following disclosures:

o     To you for disclosures of protected health information to you.

o     For the facility directory or to persons involved in your care or for other notification purposes as provided in § 164.510 of the federal privacy regulations (uses and disclosures requiring an opportunity for the individual to agree or to object, including notification to family members, personal representatives, or other persons responsible for your care, of the your location, general condition, or death).

o     For national security or intelligence purposes under § 164.512(k)(2) of the federal privacy regulations (disclosures not requiring consent, authorization, or an opportunity to object).

o     To correctional institutions or law enforcement officials under § 164.512(k)(5) of the federal privacy regulations (disclosures not requiring consent, authorization, or an opportunity to object).

o     That occurred before April 14, 2003.

We must provide the accounting within 60 days. The accounting must include the following information:

o     Date of each disclosure.

o     Name and address of the organization or person who received the protected health information.

o     Brief description of the information disclosed.

o     Brief statement of the purpose of the disclosure that reasonably informs you of the basis for the disclosure or, in lieu of such statement, a copy of your written authorization or a copy of the written request for disclosure.

The first accounting in any 12-month period is free. Thereafter, we reserve the right to charge a reasonable, cost-based fee.

·     Revoke your consent or authorization to use or disclose health information except to the extent that we have taken action in reliance on the consent or authorization.

Our Responsibilities under the Federal Privacy Standard

In addition to providing you your rights, as detailed above, the federal privacy standard requires us to take the following measures:

·     Maintain the privacy of your health information, including implementing reasonable and appropriate physical, administrative, and technical safeguards to protect the information.

·     Provide you this notice as to our legal duties and privacy practices with respect to individually identifiable health information that we collect and maintain about you.

·     Abide by the terms of this notice.

·     Train our personnel concerning privacy and confidentiality.

·     Implement a sanction policy to discipline those who breach privacy/confidentiality or our policies with regard thereto.

·     Mitigate (lessen the harm of) any breach of privacy/confidentiality.

We will not use or disclose your health information without your consent or authorization, except as described in this notice or otherwise required by law.

How to Get More Information or to Report a Problem

If you have questions and/or would like additional information, you may contact the Faith Stilen or Danielle Silva at 281-344-1808.


Examples of Disclosures for Treatment, Payment, and Health Care Operations

· If you give us consent, we will use your health information for treatment.

Example: A physician, a physician’s assistant, a therapist or a counselor, a nurse, or another member of your health care team will record information in your record to diagnose your condition and determine the best course of treatment for you. The primary caregiver will give treatment orders and document what he or she expects other members of the health care team to do to treat you. Those other members will then document the actions that they took and their observations. In that way, the primary caregiver will know how you are responding to treatment. We will also provide your physician, other health care professionals, or a subsequent health care provider copies of your records to assist them in treating you once we are no longer treating you.

· If you give us consent, we will use your health information for payment.

Example: We may send a bill to you or to a third-party payer, such as a health insurer. The information on or accompanying the bill may include information that identifies you, your diagnosis, treatment received, and supplies used.

· If you give us consent, we will use your health information for health care operations.

Example: Members of the medical staff, the risk or quality improvement manager, or members of the quality assurance team may use information in your health record to assess the care and outcomes in your cases and the competence of the caregivers. We will use this information in an effort to continually improve the quality and effectiveness of the health care and services that we provide.

·     Business associates: We provide some services through contracts with business associates.

Examples include certain diagnostic tests, a copy service to make copies of medical records, and the like. When we use these services, we may disclose your health information to the business associates so that they can perform the function(s) that we have contracted with them to do and bill you or your third-party payer for services provided. To protect your health information, however, we require the business associates to appropriately safeguard your information. After February 17, 2010, business associates must comply with the same federal security and privacy rules as we do.

· Directory: Unless you notify us that you object, we will use your name, location in the facility, general condition, and religious affiliation for directory purposes. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name.

· Notification: We may use or disclose information to notify or assist in notifying a family member, a personal representative, or another person responsible for your care, location, and general condition.

· Communication with family: Unless you object, health professionals, using their best judgment, may disclose to a family member, another relative, a close personal friend, or any other person that you identify health information relevant to that person’s involvement in your care or payment related to your care.

· Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

· Funeral directors: We may disclose health information to funeral directors consistent with applicable law to enable them to carry out their duties.

· Marketing/continuity of care: We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

· Fundraising: We may contact you as a part of a fundraising effort. You have the right to request not to receive subsequent fundraising materials.

· Food and Drug Administration (“FDA”): We may disclose to the FDA health information relative to adverse effects/events with respect to food, drugs, supplements, product or product defects, or postmarketing surveillance information to enable product recalls, repairs, or replacement.

· Workers compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

· Public health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

· Correctional institution: If you are an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.

· Law enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

· Health oversight agencies and public health authorities: If members of our work force or business associates believe in good faith that we have engaged in unlawful conduct or otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers, or the public, they may disclose your health information to health oversight agencies and/or public health authorities, such as the department of health.

· The federal Department of Health and Human Services (“DHHS”): Under the privacy standards, we must disclose your health information to DHHS as necessary to determine our compliance with those standards.

· Communication with family in waiting room: Unless you object, health professionals, using their best judgment, may disclose to a family member, another relative, a close personal friend, or any other person that you identify health information relevant to that person’s involvement in your care or payment related to your care.

Effective date: November 8, 2010

Faith A Stilen


Faith Pediatric Rehabilitation

*NOTE: the reference you is also referred to as your child*

By signing this form, I consent to the use and disclosure of protected health information about my child as written in the above examples of disclosures for treatment, payment, and health care operations.    _________________________________/________________Signature of Guardian/Date