Patient Email Consent Form "*" indicates required fields Patient Name First Last Patient Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Provider Risk of Using Email Transmitting patient information by email has a number of risks that patients should consider before using email. These include, but are not limited to, the following risks: Email can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients. Email senders can easily misaddress an email. Backup copies of email may exist even after the sender or the recipient has deleted his or her copy. Employers and online services have a right to inspect email transmitted through their system. Email can be intercepted, altered, forwarded, or used without authorization or detection. Email can be used to introduce viruses into computer systems. Email can be used as evidence in court. Emails may not be secure, including at Nittany Eye Associates, and therefore it is possible that the confidentiality of such communications may be breached by a third party. Conditions for Use of Email Providers cannot guarantee but will use reasonable means to maintain security and confidentiality of email information sent and received. Providers are not liable for improper disclosure of confidential information that is not caused by Provider’s intentional misconduct. Patient must acknowledge and consent to the following conditions: Email is not appropriate for urgent or emergency situations. A Provider cannot guarantee that any particular email will be read and responded to within a particular period of time. Emails must be concise. The patient should schedule an appointment if the issue is too complex or sensitive to discuss via email. Emails will usually be printed/scanned and filed in the patient’s medical record. Office staff may receive and read your messages. Provider will not forward patient identifiable emails outside of Nittany Eye Associates’ healthcare providers without the patient’s prior written consent, except as authorized or required by law. The patient should not use email for communication regarding sensitive medical information. Provider is not liable for breaches of confidentiality caused by the patient or any third party. It is the patient’s responsibility to follow up and/or schedule an appointment when warranted. Instructions To communicate by email, the patient shall: Avoid use of his/her employer’s computer. Put the patient’s name in the body of the email. Key in the topic (e.g.: medical question, billing question) in the subject line. Inform Provider of changes in his/her email address. Acknowledge any email received from the Provider. Take precautions to preserve confidentiality of email. Patient Acknowledgement and Agreement*I acknowledge that I have read and fully understand this consent form. I understand the risk associated with the communication of email between the Providers and me, and consent to the conditions and instructions outlined, as well as any instructions that the Providers may impose to communicate with patient by email. If I have any questions, I may inquire with my treating Provider or Nittany Eye Associates’ Privacy Officer. Yes, I acknowledge and Agree Patient Signature*CAPTCHACommentsThis field is for validation purposes and should be left unchanged.