Email Informed Consent

Although we offer a patient portal for the secure transmission of electronic health information, many patients prefer the ease of unsecured email.

We are willing to send and receive health information by unsecured email, but it is important for you to know that email is not considered to be a confidential means of communication and that it is possible for a third party to intercept and eavesdrop on those messages. While Etheridge Psychology’s electronic systems are secured, information is no longer protected by our systems once an email is sent. Information may be vulnerable while in transit and after it is received by your email server. The kinds of parties that may intercept these messages include, but are not limited to:

• People in your home or other environments who can access your device
• Your employer, if you use your work email to communicate with us
• Third parties such as server administrators and others who monitor internet traffic
• People who may “hack” email or computer

If, after reading these risks, you have decided you prefer to use our secure patient portal, please do not complete this form and contact us at (919) 600-4906.

I consent to allow my clinician or other Etheridge Psychology employee to use unsecured email to transmit to me the following protected health information: *

Yes

No

APPOINTMENTS: Information related to the scheduling of meetings or other appointments

FINANCIAL: Billing statements and other information about billing, health insurance, and payment

FORMS AND TESTS: Forms for me to complete, links to remotely administered psychological tests

QUESTIONS AND ANSWERS: Information related to my (or my dependent’s) treatment or evaluation such as answers to questions about mental health concerns, diagnosis, services, or coordination of healthcare with other providers.

MEDICAL RECORDS: Information from my medical record, such as my evaluation report, treatment summary, or any other information that contains sensitive clinical information about me (or my dependent).

If you have chosen to receive billing statements by email, do you also want billing statements to be sent by postal mail? *

Send billing statements only by email (you must check your spam folder) Send billing statements by BOTH email and regular postal mail

Patient Name *

First Name Last Name

Patient Date of Birth *

Date

Is this patient a minor (under age 18) or an adult who has been appointed a legal guardian by a court? *

Yes No

Name of parent or legally appointed guardian signing this form (note: a stepparent is not a legal guardian unless appointed by a court) *

First Name Last Name

Relationship to patient *

Parent of minor child Guardian appointed by a court for minor child or dependent adult

Email you authorize us to use to communicate with you (we can ONLY use this email address to communicate with you) *

example@example.com

Electronic Signature

By completing the following fields, you affirm that you have read this document, that you agree to the terms and conditions, and that you consent to sign this document electronically. You are not required to sign electronically and may request this document in non-electronic form. You have the right to withdraw your consent to further electronic disclosures, in writing, at any time. You have the right to receive a copy of your completed form. You may reach us by phone at (919) 600-4906, and our address is 115 Kildaire Park Dr Ste 313, Cary, NC 27518. If you are signing this document on behalf of a legal dependent (such as a minor child), you attest that you have the legal authority to sign on behalf of this patient without the approval of another person (such as a minor's other parent).

Name of person electronically signing this document

First Name Last Name

Signature

Clear

Consent for Nonsecure Communication by Email