Medcom Form 756 – Fill Out and Use This PDF

MEDICAL RECORD - CONSENT FORM

Authorization To Send And Receive Medical Information By Electronic Mail

For use of this form see, MEDCOM Supplement 1 to AR 40-66; the proponent agency is MCHO

SECTION I - PATIENT DATA

SECTION II - CONDITIONS FOR USE OF E-MAIL

Health care providers cannot guarantee but will use reasonable means to maintain security and confidentially of electronic mail (E-mail) information sent and received. You must acknowledge and consent to the following conditions:

1. E-mail is not appropriate for urgent or emergency situations. Healthcare providers will respond within	.
Contact the clinic telephonically if you have not received a response after	.

2.E-mail must be concise. You should schedule an appointment if the issue is complex or sensitive precluding discussion by E-mail.

3.E-mail should not be used for communications regarding sensitive medical conditions such as sexually transmitted diseases. HIV/AIDS, spouse or child abuse, chemical dependency, etc.

4.Medical or dental treatment facility staff may receive and read your messages.

5.E-mails related to health consultation will be copied, pasted, and filed.

SECTION III - RISKS OF USING E-MAIL

Transmitting information by E-mail has risks that you should consider these include, but are not limited to the following risks:

1.E-mails can be intercepted, altered, forwarded. or used without authorization or detection.

2.E-mails can be circulated, forwarded and stored in paper and electronic files.

3.E-mail senders can easily type in the wrong E-mail address.

4.E-mail may be lost due to technical failure during composition, transmission, and/or storage.

SECTION IV - PATIENT GUIDELINES

To communicate by E-mail, the patient shall:

1.Place the category (topic) of the communication in the subject line of the E-mail (for example, appointment, prescription, medical advice, etc.)

2.Include the patient's name, telephone number, family member prefix, and the last 4 numbers of the sponsor's social security number (for example: 30/0858) in the body of the E-mail.

3.Acknowledge receipt of the E-mail when requested to do so by a health care provider.

4.Inform the medical or dental treatment facility of changes in E-mail address by completing a new consent form.

5.Notify the health care provider of any types of information considered by the patient to be inappropriate for E-mail.

6.Take precautions to preserve the confidentiality of E-mail.

SECTION V - PATIENT ACKNOWLEDGEMENT AND AGREEMENT

I have read and fully understand the information in this authorization form. I consent to the E-mail conditions and agree to abide by the guidelines listed above. I futher understand that this E-mail relationship may be terminated if I repeatedly fail to adhere to these guidelines.

I understand and accept the risks associated with the use of unsecure E-mail communications. I further understand that, as with all means of electronic communication, there may be instances beyond the control of the family and the health care provider where information may be lost or inadvertently exposed, such as during technical failures, acts of God, acts of war, and so forth.

I understand that I have he right to revoke this authorization, in writing, at any time.

By signing this form I acknowledge the privacy risks associated with using E-mail and authorize health care providers to communicate with me or any minor dependent/ward for purpose of medical advice, education, and treatment.

(Date)	SIGNATURE of Patient or Parent/Guardian			RELATIONSHIP (if other than patient)
PATIENT IDENTIFICATION	( For typed or written entries note: Name-last, first, middle		Patient's Name			Sex
initial; hospital or medical facility)
			Year of Birth	Relationship to Sponsor	Component/Status

Organization