EMAIL COMMUNICATION CONSENT

You have asked to receive health-related email communications from CenExel RMCR ("RMCR" or "We"). RMCR is committed to accommodating your request to communicate via email but believes it is important to provide education regarding the risks associated with the use of email. Email is inherently unsecure unless it is fully encrypted and protected with the use of passwords. Encryption is a special process that makes the email unreadable by unauthorized people. Passwords help ensure that only the authorized email user can open the email program. While many email programs now use passwords, many do not use encryption. Email that is not encrypted should only be used for non-sensitive information. Also, because email may not be read immediately, email should not be used for urgent issues.  Among the risks of using email to communicate sensitive medical information are:

- Email can be forwarded, printed, and stored in numerous paper and electronic forms and be received by unintended recipients without your knowledge or agreement.

- Emails may be sent to the wrong address.

- Email is easier to forge than handwritten or signed papers.

- Copies of email may exist even after the sender or the receiver has deleted his or her copy.

- Email service providers have a right to archive and inspect emails sent through their systems.

- Email can be intercepted, altered, forwarded, or used without detection or authorization.

- Email can spread computer viruses.

- Email delivery is not guaranteed.

- Email can be used for Phishing. Phishing is a technique of obtaining sensitive personal information from individuals by pretending to be a trusted sender.

RMCR will use reasonable means to protect the security and confidentiality of email information sent and received; however, we cannot guarantee the security of email communication, thus participants must consent to the use of email.  We do not recommend the use of email to send protected health information. However, we want you to have convenient access to your health information, and if you understand the risks and are willing to accept those risks, we will provide your information via email.

Participant Name*

First Name
Last Name

Date of Birth*

Date(Required)

Email*

DO NOT PROVIDE YOUR E-MAIL ADDRESS OR COMPLETE THIS FORM IF YOU DO NOT WANT TO ACCEPT THE RISKS OF USING EMAIL TO COMMUNICATE YOUR PERSONAL HEALTH INFORMATION. IN SUCH CASE, WE WILL COMMUNICATE WITH YOU THROUGH OTHER, MORE SECURE, MEANS, SUCH AS TELEPHONE OR MAIL.
By signing below, you agree that you have read and understand the risks of using email and consent to RMCR sending your protected health information by email. You understand that RMCR will use the email address information set forth below. You understand that you must tell us in writing if your email address changes and you want us to send your information to a different email address. You also understand that anyone who can access your email might be able to see your health information, and that emails can be lost, intercepted, or misdirected. You understand that you may withdraw this consent at any time by providing written notice to RMCR at 701 E. Hampden Ave., Suite 510, Englewood, CO 80113.

Signature*

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Name Of Signer*

First Name
Last Name

Relationship to Participant*

Untitled(Required)

Agreement*

Untitled(Required)

CenExel RMCR | 701 E. Hampden Avenue, Suite 510 Englewood, CO 80113
Tel (303) 357-5455 | Fax (303) 357-5459

We are committed to keeping your personal information safe and secure. Any information collected will not be sold or shared with third parties.

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