Patient Portal Informed Consent and User Agreement
INTRODUCTION: Wrightstown Family Medicine offers this communication tool as a courtesy to our patients and others, such as parents, responsible for or involved in their care. Wrightstown Family Medicine has performed a risk analysis of this communication tool and has implemented reasonable and appropriate security measures to protect patient privacy.
REFERENCES:
*Wrightstown Family Medicine's Notice of Privacy Practices.
*Business associate agreements with vendors involved in providing the service.
PRIVACY AND SECURITY: As stated above, Wrightstown Family Medicine has implemented, in its opinion, reasonable and appropriate security measures as required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). These measures include user authentication, firewalls, encryption, malware prevention and intrusion detection. The best technical security can be defeated, however, particularly if you do not protect your user ID and password to access the portal. If you believe that these security measures have been compromised, immediately change your password and report the matter to Wrightstown Family Medicine's Security Officer at (215) 598-1200. Even with our security measures and your assistance in protecting your user ID and password, we cannot guarantee that your health information, including financial, demographic, and lifestyle information, as well as clinical information, will not be compromised. Knowing this, if you still want to participate in our patient portal and you are willing to adhere to the conditions below, please sign at the bottom of this form.
PATIENT PORTAL SERVICES: The patient portal provides the following services, although we reserve the right to offer further services:
*Scheduling of appointments
*Medication refill requests
*Communication of laboratory results from our clinicians to our patients
*Read-only access to patient electronic health records. If patients believe that their re3cords are inaccurate, the Wrightstown Family Medicine Notice of Privacy Practices specifies how to request correction or amendment.
*Alerts (need for an appointment, date/time of an appointment, expiring prescription, and so forth).
*Access to educational materials.
PROHIBITED PORTAL SERVICES: Proper medical practice and legal requirements prohibit Wrightstown Family Medicine from performing certain services through a patient portal, such as the following:
*Diagnostic imaging services
*Emergency services. Patients who need emergency care should physically go to an emergency department or an urgent care facility or simply dial 911.
* Requests for refill medications prescribed by physicians other than those of Wrightstown Family Medicine.
*Diagnosis and treatment decisions. Such services require the physician to actually see the patient and often also to obtain a medical history and order diagnostic tests. If you want your health issue to be diagnosed and treated, use the portal to schedule an appointment unless it is an emergency. In that event, follow the guidance above.
Wrightstown Family Medicine provides this patient portal as a courtesy for our patients and does not charge a service fee. If, however, patients misuse the portal, we reserve the right to terminate those patients' access or otherwise modify the services offered through the portal.
INSTRUCTIONS: Once you have signed this Patient Portal Informed Consent and User Agreement, you must provide us your email address. Upon re3ceipt of your email address, we will provide instructions as to how to access the portal.
PATIENT INFORMED CONSENT AND AGREEMENT: The undersigned has read and understands this Patient Portal Informed Consent and Agreement Form. Understanding that some risks exist with use of this patient portal, I agree to the conditions specified and consent to the use of my individually identifiable health information in this manner. I also consent to any instructions that my physician or other clinician may impose for Patient Portal communications.
Parent/Guardian Signature if Necessary
HIPAA Documents Resource Center CD, 6th edition. copyright 2001-2014 Jonathan P Tomes, Veterans Press, Inc., and EMR Legal, Inc. All rights reserved.
