EFTA00316616.pdf

07/25/2014 04:16am MSH 2122418866 #149 Pase 02/06 Mount Fatuity Practice Sinai Doctors CONSENT FOR COMMUNICATION VIA E-MAIL (Pro vider-Patient) I, a.i.717.gt-EN GPtatt,J, hereby consent to have my physician, . , communicate .with me or members of his/her staff, where appropriate or other physicians, nurse practitioners and pharmacists via e-mail regarding the following aspe cts of my medical care and treatment: (test results, prescription s, appointments, billing, etc.). I understand that e-mail is not a confidential method of communication. I further understand that there is a risk that e mail communications between my physician and me or members of my physician's office staff or between my physicia n and other physicians, nurse practitioners and pharmacists regarding my medical care and treatment may be intercepted by third parties or transmitted to' unintended parties. I also understand that any e-mail communications between my physician and me or members of his/her offi ce staff, or between my physician and other physicians, nurs epractitioners or pharmacists regarding'my medical care and treatmen t will be printed out and made a part of my medical record. I understa nd that in an urgent or emergent situation I should call my provider or go to the Emergency Room and not rely on e-mail. EFTA00316616