Patient email and text message informed consent

You may give permission to each of the entities comprising each of the Organized Health Care Associations to communicate with you by email and text message. This form provides information about the risks of the forms of communication, guidelines for email/text communication, and how we use email/text communication. It also will be used to document your consent for communication with you by email and text message.

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1) How we will use email and text messaging:

We use these methods to communicate only non-sensitive and non-urgent issues. All communications to or from you may be made a part of your medical record. You have the same right of access to such communications as you do to the remainder of your medical record. We will not disclose your emails or text messages to researchers or others unless allowed by state or federal law. Please refer to our Notice of Privacy Practices for information as to permitted uses of your health information and your rights regarding privacy matters.

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2) Risk of using email and text messages:

The use of email and text message has a number of risks that you should consider. These risks include, but are not limited to the following:

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a) Emails and texts can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients.

b) Senders can easily misaddress an email or text and send the information to an undesired recipient.

c) Backup copies of emails and texts may exist even after the sender and/or recipient has deleted his or her copy.

d) Employers and online services have a right to inspect emails and texts sent through their company systems.

e) Emails and texts can be intercepted, altered, forwarded or used without authorization or detection.

f) Emails and texts can be used as evidence in court.

g) Email and text messaging may not be secure, and therefore it is possible that a third party may breach the confidentiality of such communications.

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3) Conditions of the use of email and text message:

NeuroDiagnostics, Inc. d/b/a Synaps Dx cannot guarantee but will use reasonable means to maintain security and confidentiality of email/text information sent and received. You must acknowledge and consent to the following conditions:

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a) IN A MEDICAL EMERGENCY, DO NOT USE EMAIL, CALL 911. Do not email for urgent problems. If you have an urgent problem during regular business hours, please call 301-294-7026. Urgent messages or needs should be relayed to us by using regular telephone communication and may include text messages.

b) Emails should not be time sensitive. While we try to respond to email messages daily, we cannot guarantee that any particular email will be read and responded to within any particular period of time. If you have not heard back from us within three days, call our office to follow up if we have received your email.

c) You should speak to our office directly to discuss complex and/or sensitive situations rather than send email or text messages regarding such situations.

d) Email and text messages may be filed electronically into your medical record.

e) Clinical staff will not forward your identifiable email/texts to outside parties without your written consent, except as authorized by law.

f) You should use your best judgment when considering the use of email or text messages for communication of sensitive medical information. Clinical staff are not responsible for the content of messages.

g) NeuroDiagnostics, Inc. d/b/a Synaps Dxis not liable for breaches of confidentiality caused by you or any third party.

h) It is your responsibility to follow up with NeuroDiagnostics, Inc. d/b/a Synaps Dx if warranted.

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4) Withdrawal of consent:

I understand that I may revoke this consent at any time by so advising NeuroDiagnostics, Inc. d/b/a Synaps Dxn writing. My revocation of consent will not affect my ability to obtain future health care nor will it cause the loss of any benefits to which I am entitled.

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5) Patient Acknowledgement and Agreement:

I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the use of email and text messaging as a form of communication between NeuroDiagnostics, Inc. d/b/a Synaps Dx and me, and consent to the conditions and instruction outlined, as well as any other instructions NeuroDiagnostics, Inc. d/b/a Synaps Dx may impose to communicate with me by email or text message.