Patient E-consent Form

PATIENT E-CONSENT FORM

WHEREAS

WHEREAS, Patient Name: (the "Patient") seeks healthcare services from Provider Name: ;

WHEREAS, the Patient is asked to provide informed consent for certain procedures, treatments, communications, and record‑keeping in electronic form and to receive electronic communications and to sign electronically; and

WHEREAS, the Patient affirms understanding of the nature of electronic consent, the security measures and the rights to revoke consent as set forth below;

PATIENT IDENTIFICATION

SCOPE OF SERVICES

RISKS, BENEFITS, AND ALTERNATIVES

ELECTRONIC COMMUNICATIONS AND SIGNATURES

The Patient authorizes Provider to use electronic means to communicate protected health information, send appointment reminders, obtain informed consent, and to accept electronic signatures. Electronic communications may include email, patient portal messages, SMS/text, and other electronic messaging. The Patient understands that while reasonable safeguards are used, electronic transmission is not completely secure.

PAYMENT RESPONSIBILITY

The Patient understands financial responsibility for services and authorizes electronic billing and statements. Estimated amount: $ . Payment schedule or arrangements, if any, are set out below.

TERM, REVOCATION, AND TERMINATION

This consent becomes effective upon the date signed below and remains in effect until: Start Date: End Date:

The Patient may revoke this consent at any time by delivering written notice to Provider. Revocation becomes effective upon Provider's receipt and does not apply to actions taken in reliance on prior consent. Notice period (if required by Provider):

CONFIDENTIALITY AND DATA SECURITY

Provider will safeguard protected health information in accordance with applicable law. Electronic transmissions may be encrypted. The Patient acknowledges that electronic transmission carries some risk and releases Provider from liability for unauthorized access unless due to Provider's gross negligence or willful misconduct.

GOVERNING LAW; ENTIRE AGREEMENT

This Consent will be governed by the laws of the state of without regard to conflict of law principles. This document constitutes the entire agreement regarding electronic consent between the Patient and Provider with respect to the matters herein.

ACKNOWLEDGMENTS

By checking the boxes below and signing, the Patient acknowledges that they have read and understand the information provided, have had an opportunity to ask questions and have received answers satisfactory to them, and agree to the use of electronic records, communications, and signatures as set forth above.

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