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Patient portal practice consent


Purpose of this Form
We offer a secure viewing and communication as a service to patients who wish to view parts of their records and communicate with our staff and physicians. Secure messaging can be a valuable communications tool, but has certain risks. In order to manage these risks we need to impose some conditions of participation.

This form is intended to show that you have been informed of these risks and the conditions of participation, and that you accept the risks and agree to the conditions of participation.

How the Secure Patient Portal Works
A secure web portal is a kind of webpage that uses encryption to keep unauthorized persons from reading communications, information, or attachments. Secure messages and information can only be read by someone who knows the right password or pass-phrase to log in to the portal site. Because the connection channel between your computer and the Web site uses secure sockets layer technology you can read or view information on your computer, but it is still encrypted in transmission between the Web site and your computer.

Protecting Your Private Health Information and Risks:
This method of communication and viewing prevents unauthorized parties from being able to access or read messages while they are in transmission. No transmission system is perfect and we will do our best to maintain electronic security. However, keeping messages secure depends on two additional factors: the secure message must reach the correct email address, and only the correct individual (or someone authorized by that individual) must be able to get access to it.
Only you can make sure these two factors are present. We need you to make sure we have your correct email address and are informed if it ever changes. You also need to keep track of who has access to your email account so that only you, or someone you authorize, can see the messages you receive from us.
If you pick up secure messages from a web site, you need to keep unauthorized individuals from learning your password. If you think someone has learned your password, you should promptly go to the web site and change it.

Patient Acknowledgement and Agreement:
I acknowledge that I have read and fully understand this consent form and the Policies and Procedures Regarding the Patient Portal that appears at log in. I understand the risks associated with online communications between my physician and me, and consent to the conditions outlined herein. In addition, I agree to follow the instructions set forth herein and including the policies and procedures as set forth in the log in screen, as well as any other instructions that my physician may impose to communicate with patients via online communications. All of my questions have been answered and I understand and concur with the information provided in the answers.

eClinicalWorks Patient Portal Consent Form

Online Communications Informed Consent

Instructions for Using Online Communications
You agree to take steps to keep your online communications to and from me confidential including:
Do not store messages on your employer-provided computer; otherwise personal information could be accessible or owned by your employer.
Use a screen saver or close your messages instead of leaving your  messages on the screen for passersby to read and keep your password safe and private.
Do not allow other individuals or other third parties access to the computer(s) upon which you store medical communications.
Do not use email for medical communications.  Standard e-mail lacks security and privacy features and may expose medical communications to employers or other unintended third parties.
Withdrawal of this Informed Consent must be done by written online communications or in writing to my office.

Charges for Using Online Communications:
My office may charge for certain online communications.  You will be informed in advance when/if these charges apply and you will be responsible for payment of these charges if you accept and use any fee-based service.  You may choose to contact your insurance carrier to determine if they cover online communications.

Conditions of  Using Online Communications:
The following agreements and procedures relate to online communications:
eclinicalWeb office will keep a copy of all medically important online communications in your medical record in encrypted format. 
You should print or store (on a computer or storage device owned and controlled by you) a copy of all online communications that are important to you.
eClinicalWeb will not forward online communications with you to third parties except as authorized or required by law.
Online communications will be used only for limited purposes.  Online communications cannot be used for emergencies or time-sensitive matters.  It should be used with caution.  If there is other information that you don't want transmitted via online communications, you must inform your practice. eClinicalWeb cannot be held responsible.
Please note that online communications should never be used for emergency communications or urgent requests.  These should occur via telephone or using existing emergency communications tools.
eClinicalWeb is not liable for improper disclosure of confidential information
Follow-up is solely your responsibility.  You are responsible for scheduling any necessary appointments and for determining if an unanswered online communication was not received.
You are responsible for taking steps to protect yourself from unauthorized use of online communications, such as keeping your password confidential.  eClinicalWeb is not responsible for breaches of confidentiality caused by you or an independent third party.
I will not engage in any illegal online communications, including illegally practicing medicine across state lines.

Access to Online Communications
The following pertains to access to and use of online communications:
Online communications does not decrease or diminish any of the other ways in which you can communicate with your provider.  It is an additional option and not a replacement.  .
eClinicalWeb may stop providing online communications with you or change the services I provide online at any time without prior notification to you.

Risks of Using Online Communications
All medical communications carry some level of risk.  While the likelihood of risks associated with the use of online communications, particularly in a secure environment, is substantially reduced, the risks are nonetheless real and very important to understand.  It is very important that you consider these risks each time you plan to communicate with me, and communicate in such a fashion as to mitigate the potential for any of these risks.  These risks include, but are not limited to:
Online communications may travel much further than you planned.  It is easier for online communications to be forwarded, intercepted, or even changed without your knowledge.
Online communication is easier to falsify than handwritten or signed hard copies.  A dishonest person could attempt to impersonate you to try to get your medical records.
It is harder to get rid of an online communication.  Backup copies may exist on a computer or in cyberspace, even after you have deleted your copies.
Online communication is not private simply because it relates to your own medical information.  I use a secure network to avoid using standard e-mail or e-mail systems provided by employers.  Employers and online services have a right to inspect and keep online communications transmitted through their system.
Online communications are also admissible as evidence in court.
Online communications may disrupt or damage your computer if a computer virus is attached.

Patient Acknowledgement and Agreement
I acknowledge that I have read and fully understand this consent form.  I understand the risks associated with  online communications between my physician and me, and consent to the conditions outlined herein.  In addition, I agree to follow the instructions set forth herein, as well as any other instructions that my physician may impose to communicate with patients via online communications.  I have had a chance to ask any questions that I had and to receive answers.  I have been proactive about asking questions related to this consent agreement.  All of my questions have been answered and I understand and concur with the information provided in the answers.

Other important notices

Our goal here at Houston Thyroid and Endocrine, PLLC is to provide quality service to all 
of our clients in a timely manner. Failure to keep scheduled appointments is costly to 
both the clinic and you as a patient. This letter is to inform you of our policy concerning 
No Shows. Patients who are unable to keep their appointments are requested to give 
24- hour notice prior to their appointments. We realize this is not always possible and 
the practice will consider each individual case. Providing such notice allows the clinic 
time to offer other persons the opportunity to see our providers, thus using the time 
more efficiently. If an established patient fails to provide notice twice, it will be 
necessary to charge them a $25.00 fee that will be billed to his/her account. If a patient 
has confirmed his/her appointment and fails to keep that appointment, there will be a 
$50.00 fee billed to his/her account. If a patient fails to keep his/her appointments on a 
regular basis, or has missed 3 consecutive appointments, he/she may be dismissed from 
the practice, and a letter of dismissal will follow.  


If you have any questions about this Notice please contact 
our Privacy Officer  
This Notice of Privacy Practices describes how we may use and disclose your protected 
health information to carry out treatment, payment or health care operations and for other 
purposes that are permitted or required by law.  It also describes your rights to access and 
control your protected health information.  ?Protected health information? is information 
about you, including demographic information, that may identify you and that relates to 
your past, present or future physical or mental health or condition and related health care 
We are required to abide by the terms of this Notice of Privacy Practices.  We may 
change the terms of our notice, at any time.  The new notice will be effective for all 
protected health information that we maintain at that time.  Upon your request, we will 
provide you with any revised Notice of Privacy Practices.  You may request a revised 
version by accessing our website, or calling the office and requesting that a revised copy 
be sent to you in the mail or asking for one at the time of your next appointment. 
Your protected health information may be used and disclosed by your physician, our 
office staff and others outside of our office who are involved in your care and treatment 
for the purpose of providing health care services to you.  Your protected health 
information may also be used and disclosed to pay your health care bills and to support 
the operation of your physician?s practice. 
Following are examples of the types of uses and disclosures of your protected health 
information that your physician?s office is permitted to make. These examples are not 
meant to be exhaustive, but to describe the types of uses and disclosures that may be 
made by our office. 

Treatment:  We will use and disclose your protected health information to provide, 
coordinate, or manage your health care and any related services.  This includes the 
coordination or management of your health care with another provider. For example, we 
would disclose your protected health information, as necessary, to a home health agency 
that provides care to you.  We will also disclose protected health information to other 
physicians who may be treating you. For example, your protected health information may 
be provided to a physician to whom you have been referred to ensure that the physician 
has the necessary information to diagnose or treat you.  In addition, we may disclose your 
protected health information from time-to-time to another physician or health care 
provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes 
involved in your care by providing assistance with  your health care diagnosis or 
treatment to your physician. 
Payment:  Your protected health information will be used and disclosed, as needed, to 
obtain payment for your health care services provided by us or by another provider.  This 
may include certain activities that your health insurance plan may undertake before it 
approves or pays for the health care services we recommend for you such as: making a 
determination of eligibility or coverage for insurance benefits, reviewing services 
provided to you for medical necessity, and undertaking utilization review activities.  For 
example, obtaining approval for a hospital stay may require that your relevant protected 
health information be disclosed to the health plan  to obtain approval for the hospital 
Health Care Operations:  We may use or disclose, as needed, your protected health 
information in order to support the business activities of your physician?s practice.  These 
activities include, but are not limited to, quality assessment activities, employee review 
activities, training of medical students, licensing, fundraising activities, and conducting or 
arranging for other business activities. 
We will share your protected health information with third party ?business associates? 
that perform various activities (for example, billing or transcription services) for our 
practice.  Whenever an arrangement between our office and a business associate involves 
the use or disclosure of your protected health information, we will have a written contract 
that contains terms that will protect the privacy of your protected health information.
We may use or disclose your protected health information, as necessary, to provide you 
with information about treatment alternatives or other health-related benefits and services 
that may be of interest to you.  You may contact our Privacy Officer to request that these 
materials not be sent to you.
We may use or disclose your demographic information and the dates that you received 
treatment from your physician, as necessary, in order to contact you for fundraising 
activities supported by our office.  If you do not want to receive these materials, please 
contact our Privacy Officer and request that these fundraising materials not be sent to 
Other Permitted and Required Uses and Disclosures That May Be Made Without 
Your Authorization or Opportunity to Agree or Object   
We may use or disclose your protected health information in the following situations 
without your authorization or providing you the opportunity to agree or object.  These 
situations include: 
Required By Law:  We may use or disclose your protected health information to the 
extent that the use or disclosure is required by law.  The use or disclosure will be made in 
compliance with the law and will be limited to the relevant requirements of the law.  You 
will be notified, if required by law, of any such uses or disclosures.  
Public Health:  We may disclose your protected health information for public health 
activities and purposes to a public health authority that is permitted by law to collect or 
receive the information.  For example, a disclosure may be made for the purpose of 
preventing or controlling disease, injury or disability. 
Communicable Diseases:  We may disclose your protected health information, if 
authorized by law, to a person who may have been exposed to a communicable disease or 
may otherwise be at risk of contracting or spreading the disease or condition. 
Health Oversight:  We may disclose protected health information to a health oversight 
agency for activities authorized by law, such as audits, investigations, and inspections.  
Oversight agencies seeking this information include government agencies that oversee 
the health care system, government benefit programs, other government regulatory 
programs and civil rights laws.   
Abuse or Neglect:  We may disclose your protected health information to a public health 
authority that is authorized by law to receive reports of child abuse or neglect.  In 
addition, we may disclose your protected health information if we believe that you have 
been a victim of abuse, neglect or domestic violence to the governmental entity or agency 
authorized to receive such information.  In this case, the disclosure will be made 
consistent with the requirements of applicable federal and state laws.
Food and Drug Administration:  We may disclose your protected health information to 
a person or company required by the Food and Drug Administration for the purpose of 
quality, safety, or effectiveness of FDA-regulated  products or activities including, to 
report adverse events, product defects or problems, biologic product deviations, to track 
products; to enable product recalls; to make repairs or replacements, or to conduct post 
marketing surveillance, as required.  
Legal Proceedings:  We may disclose protected health information in the course of any 
judicial or administrative proceeding, in response to an order of a court or administrative 
tribunal (to the extent such disclosure is expressly authorized), or in certain conditions in 
response to a subpoena, discovery request or other lawful process.   
Law Enforcement:  We may also disclose protected health information, so long as 
applicable legal requirements are met, for law enforcement purposes.  These law 
enforcement purposes include (1) legal processes and otherwise required by law, 
(2) limited information requests for identification and location purposes, (3) pertaining to 
victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, 
(5) in the event that a crime occurs on the premises of our practice, and (6) medical 
emergency (not on our practice?s premises) and it is likely that a crime has occurred.   
Coroners, Funeral Directors, and Organ Donation:  We may disclose protected health 
information to a coroner or medical examiner for identification purposes, determining 
cause of death or for the coroner or medical examiner to perform other duties authorized 
by law.  We may also disclose protected health information to a funeral director, as 
authorized by law, in order to permit the funeral director to carry out their duties.  We 
may disclose such information in reasonable anticipation of death.  Protected health 
information may be used and disclosed for cadaveric organ, eye or tissue donation 
Research:  We may disclose your protected health information to researchers when their 
research has been approved by an institutional review board that has reviewed the 
research proposal and established protocols to ensure the privacy of your protected health 
Criminal Activity:  Consistent with applicable federal and state laws, we may disclose 
your protected health information, if we believe that the use or disclosure is necessary to 
prevent or lessen a serious and imminent threat to the health or safety of a person or the 
public.  We may also disclose protected health information if it is necessary for law 
enforcement authorities to identify or apprehend an individual.   
Military Activity and National Security:  When the appropriate conditions apply, we 
may use or disclose protected health information of individuals who are Armed Forces 
personnel (1) for activities deemed necessary by appropriate military command 
authorities; (2) for the purpose of a determination by the Department of Veterans Affairs 
of your eligibility for benefits, or (3) to foreign military authority if you are a member of 
that foreign military services.  We may also disclose your protected health information to 
authorized federal officials for conducting national security and intelligence activities, 
including for the provision of protective services  to the President or others legally 
Workers? Compensation:  We may disclose your protected health information as 
authorized to comply with workers? compensation laws and other similar legallyestablished programs. 
Inmates:  We may use or disclose your protected health information if you are an inmate 
of a correctional facility and your physician created or received your protected health 
information in the course of providing care to you.
Uses and Disclosures of Protected Health Information Based upon Your Written 
Other uses and disclosures of your protected health information will be made only with 
your written authorization, unless otherwise permitted or required by law as described 
below.  You may revoke this authorization in writing at any time.  If you revoke your 
authorization, we will no longer use or disclose your protected health information for the 
reasons covered by your written authorization.  Please understand that we are unable to 
take back any disclosures already made with your authorization.
Other Permitted and Required Uses and Disclosures That Require Providing You 
the Opportunity to Agree or Object 
We may use and disclose your protected health information in the following instances.  
You have the opportunity to agree or object to the use or disclosure of all or part of your 
protected health information.  If you are not present or able to agree or object to the use 
or disclosure of the protected health information,  then your physician may, using 
professional judgement, determine whether the disclosure is in your best interest.  
Facility Directories: Unless you object, we will use and disclose in our facility directory 
your name, the location at which you are receiving care, your general condition (such as 
fair or stable), and your religious affiliation.  All of this information, except religious 
affiliation, will be disclosed to people that ask for you by name.  Your religious 
affiliation will be only given to a member of the clergy, such as a priest or rabbi. 
Others Involved in Your Health Care or Payment for your Care:  Unless you object, 
we may disclose to a member of your family, a relative, a close friend or any other person 
you identify, your protected health information that directly relates to that person?s 
involvement in your health care.  If you are unable to agree or object to such a disclosure, 
we may disclose such information as necessary if we determine that it is in your best 
interest based on our professional judgment.  We may use or disclose protected health 
information to notify or assist in notifying a family member, personal representative or 
any other person that is responsible for your care of your location, general condition or 
death.  Finally, we may use or disclose your protected health information to an authorized 
public or private entity to assist in disaster relief efforts and to coordinate uses and 
disclosures to family or other individuals involved in your health care. 
Following is a statement of your rights with respect to your protected health information 
and a brief description of how you may exercise these rights.  
You have the right to inspect and copy your protected health information.  This 
means you may inspect and obtain a copy of protected health information about you for 
so long as we maintain the protected health information.  You may obtain your medical 
record that contains medical and billing records and any other records that your physician 
and the practice uses for making decisions about you.  As permitted by federal or state 
law, we may charge you a reasonable copy fee for a copy of your records.   
Under federal law, however, you may not inspect or  copy the following records: 
psychotherapy notes; information compiled in reasonable anticipation of, or use in, a 
civil, criminal, or administrative action or proceeding; and laboratory results that are 
subject to law that prohibits access to protected health information. Depending on the 
circumstances, a decision to deny access may be reviewable.  In some circumstances, you 
may have a right to have this decision reviewed.  Please contact our Privacy Officer if 
you have questions about access to your medical record.   
You have the right to request a restriction of your protected health information.  
This means you may ask us not to use or disclose any part of your protected health 
information for the purposes of treatment, payment or health care operations.  You may 
also request that any part of your protected health information not be disclosed to family 
members or friends who may be involved in your care or for notification purposes as 
described in this Notice of Privacy Practices.  Your request must state the specific 
restriction requested and to whom you want the restriction to apply.   
Your physician is not required to agree to a restriction that you may request.  If your 
physician does agree to the requested restriction,  we may not use or disclose your 
protected health information in violation of that restriction unless it is needed to provide 
emergency treatment.  With this in mind, please discuss any restriction you wish to 
request with your physician.  You may request a restriction by written letter mailed to 
our current address.    
You have the right to request to receive confidential communications from us by 
alternative means or at an alternative location. We will accommodate reasonable 
requests. We may also condition this accommodation by asking you for information as to 
how payment will be handled or specification of an alternative address or other method of 
contact.  We will not request an explanation from you as to the basis for the request. 
Please make this request in writing to our Privacy Officer. 
You may have the right to have your physician amend your protected health 
information.   This means you may request an amendment of protected health 
information about you in a designated record set for so long as we maintain this 
information.  In certain cases, we may deny your request for an amendment.  If we deny 
your request for amendment, you have the right to file a statement of disagreement with 
us and we may prepare a rebuttal to your statement and will provide you with a copy of 
any such rebuttal.  Please contact our Privacy Officer if you have questions about 
amending your medical record.    
You have the right to receive an accounting of certain disclosures we have made, if 
any, of your protected health information.  This right applies to disclosures for 
purposes other than treatment, payment or health care operations as described in this
Notice of Privacy Practices.  It excludes disclosures we may have made to you if you 
authorized us to make the disclosure, for a facility directory, to family members or 
friends involved in your care, or for notification  purposes, for national security or 
intelligence, to law enforcement (as provided in the privacy rule) or correctional 
facilities, as part of a limited data set disclosure.  You have the right to receive specific 
information regarding these disclosures that occur  after April 14, 2003. The right to 
receive this information is subject to certain exceptions, restrictions and limitations.   
You have the right to obtain a paper copy of this notice from us, upon request, even if 
you have agreed to accept this notice electronically. 
You may complain to us or to the Secretary of Health and Human Services if you believe 
your privacy rights have been violated by us.  You  may file a complaint with us by 
notifying our Privacy Officer of your complaint.  We will not retaliate against you for 
filing a complaint.  
You may contact our Privacy Officer,  at 713.795.0770 for further 
information about the complaint process.   
This notice was published and becomes effective on 9-24-2011.