Purpose of the form:

Adult Internal Medicine offers secure viewing and communication as a service to our patients who wish to view their records and communicate with the staff. Secure messaging can be a valuable communication 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 gave been informed of these risks and conditions, and that you accept and agree to these conditions.

How the secure patient portal works:

A secure web portal is a type of webpage that uses encryption to keep unauthorized users from reading communications, information or attachments. Secure messages and information can only be read by someone who knows the right password to log into the portal site. The connection channel between your computer and the website uses secure sockets layer technology so you can read or view information on your computer, but it is still encrypted in transmission between the website 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. No transmission system is perfect and we will do our best to maintain electronic security. However, keeping messages secure depends on two additional factors:

  1. The secure message must reach the correct email address and
  2. Only the correct individual must be able to have access to the message

Only you can make sure these two factors are present. It is imperative that our practice has your correct email address and that you inform us of any 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 message from us. You are responsible for protecting yourself from unauthorized users and protecting your password. If you think someone has learned your password, you should promptly go to the website and change it.

Types of Online Communication/Messaging:

Online communications should never be used for emergency or urgent requests. If you have an emergency or an urgent request, you should contact the office via telephone. If you submit a request or comment it will be handled by the staff but will not go directly to the provider. If there is information that you don’t want transmitted via online communication, please inform the office.

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. I understand the risks associated with online communication between the office and me, and consent to the conditions outlined here. In addition, I agree to follow the instructions set forth, including the policies and procedures in the log in screen as well as any other instructions that my physician may impose with me. I understand and agree with the information that I have provided.

Patient Name:

Email address:



Patient portal consent Form Download