The following is a model form to be used with patients before communicating via email.  The form should be modified to accurately reflect your desired uses and office practices.  Just as you will want your patient to abide by the terms set forth therein, remember that you and your staff will be responsible for following them as well.

Click here to access a printable version of this form.


As a supplement to your in-office appointments, I am inviting you to use email to communicate with my practice.  Set forth below are policies outlining when and how email should be utilized to maintain your privacy and to enhance communication as well as a place for you to acknowledge your consent to its use.  Your decision to utilize email is strictly voluntary and your consent may be rescinded at any time.  Email will be accessed by Dr. __________ or a staff member ________________ (specify when/how often email will be accessed).  You may expect any required response ________________ (indicate expected response time).

When may I use email to communicate with Dr. ___________?

Email may be used to (list allowed uses)

  • Prescription refill requests
  • Appointment requests
  • Other matters not requiring an immediate response

When should I NOT use email to communicate with Dr. ________________?

Email should never be used (list unacceptable uses)

  • In an emergency
  • If you are experiencing any desire to harm yourself or others
  • If you are experiencing a severe medication reaction
  • If you need an immediate response

What are the advantages to using email?

  • Unlike trading voicemail messages, email allows you to see exactly the question the doctor is responding to and to have a written record of that exchange for future reference.
  • Email allows for the rapid transmission of forms or other paperwork such as information regarding your medications/condition

What are the risks of using email?

Risks of communicating via email include but are not limited to:

  • Email may be seen by unintended viewers if addressed incorrectly
  • Email may be intercepted by hackers and redistributed
  • Someone posing as you could access your information.
  • Email can be used to spread computer viruses
  • There is a risk that emails may not be received by either party in a timely matter as it may be caught by junk/spam filters
  • Emails are discoverable in litigation and may be used as evidence in court.
  • Emails can be circulated and stored by unintended recipients
  • Statements made via email may be misunderstood thus creating miscommunication and/or negatively affecting treatment
  • There may be an unanticipated time delay between messages being sent and received

What happens to my messages?

  • Emails will be printed out and maintained as a permanent part of your medical record
  • As part of your permanent record, they will be released along with the rest of the record upon your authorization or when the doctor is otherwise legally required to do so.
  • Messages may be seen by staff for the purpose of filing or carrying out requests (e.g., appointment scheduling) or when Dr. __________________ is away from the office.

What are my obligations?

  • I must let Dr. ____________ know immediately if my email address changes.
  • If I do not receive a response from Dr. ____________ in the time frame indicated (state expected response time), I will contact him/her by telephone if a response is needed.
  • I will use email communication only for the purposes stated above.
  • I will advise Dr. ____________ in writing should I decide that I would prefer not to continue communicating via email
  • I understand that email may only be used to supplement my appointments with Dr. ______________ and not as a substitute for them.
  • To avoid possible confusion, I will not use internet slang or short-hand when communicating via email

What steps has Dr. _____________ taken to protect the privacy of my email communications?

Dr. __________________ (list steps taken)

  • Has installed software for encrypting email messages (Note: if you are not using encrypted email, you should indicate this clearly.)
  • Set up a password protected screen-saver on his computer
  • Educated staff on the appropriate use and protection of email
  • Does not access patient email from public Wi-Fi hotspots
  • Does not allow family members access to his personal work computer
  • Will not transmit highly sensitive information via email
  • Will not forward patient email to third-parties without your express consent
  • Will verify email addresses before sending messages.

What steps can I take to protect my privacy?

  • Do not use your work computer to communicate with Dr. _______________ as your employer has a right to inspect emails sent through the company’s system.
  • Do not use a shared email account to transmit messages.
  • Log out of your email account if you will be away from your computer.
  • Carefully check the address before hitting “send” to ensure that you are sending your message to the intended receiver.
  • Avoid writing or reading emails on a mobile device in a public place.
  • Avoid accessing email on a public Wi-Fi hotspot.
  • Make certain that your email is signed with your first and last name and include your telephone number and date of birth to avoid possible mix up with patients with same or similar names.


By signing below, I consent to the use of email communication between myself/___________ (name of patient) and Dr. _________.  I recognize that there are risks to its use, and despite Dr. __________’s best efforts, he/she cannot absolutely guarantee confidentiality.  I understand and accept those risks and the policies for email use outlined in the form.  I further agree to follow these policies and agree that should I fail do so, Dr. _______________ may cease to allow me to use email to communicate with him/her.  I also understand that I may withdraw my consent to communicate via email at any time by notifying Dr. ________________ in writing.


____________________________________                                         ___________________________
Name of Patient/Guardian                                                                          Date


Signature of Patient/Guardian                                                                   Email Address


Click here to access a printable version of this form.


The content of this article (“Content”) is for informational purposes only. The Content is not intended to be a substitute for professional legal advice or judgment, or for other professional advice.  Always seek the advice of your attorney with any questions you may have regarding the Content.  Never disregard professional legal advice or delay in seeking it because of the Content.

(C) Copyright 2015 Professional Risk Management Services, Inc. (PRMS®)



(800) 245-3333