AGREEMENT
REGARDING INTERNET COMMUNICATIONS (BACK TO HOME)
Ann
Arbor Hematology Oncology Associates
invites our patients to use the Internet to ask general questions about our
practice, make appointments for return visits, request refills for prescription
drugs, ask questions regarding insurance or bills and obtain results of routine
tests such as blood counts and coumadin monitoring.
If you wish to use this service, please carefully
read the following agreement, sign at the bottom of the form, and either mail
the agreement to our office or hand it to the secretary when you come in for
your next appointment. We will
provide you with a PIN (personal identification number) that must be used with
all Internet correspondence.
| Your
medical record and all information regarding your medical condition are
confidential. The same rules of confidentiality apply to e-mail and other
Internet communications. We will not respond to inquiries from friends or
relatives or provide any type of information that may violate your
confidentiality. Do not share your PIN with anyone. All information exchanged via e-mail or forms will be
included as a permanent part of your medical record. If your records are
requested for continuation of care, insurance reviews, litigation, etc.,
copies of Internet communications will be included. |
| Our
Internet server is a "secure" server. This means that all
information shared through our server is encrypted to protect your privacy.
However, we cannot guarantee that information exchanged over the Internet
won't be misdirected or intercepted. Please do not use e-mail for questions
or issues that you want to keep confidential!
We discourage the use of e-mail to ask questions directly related to
your medical health. Please do not include credit card numbers or other
sensitive information in your e-mails. |
| E-mail
messages are taken off the computer by our physicians, nurses, secretaries,
insurance staff, medical records department and medical assistants. We will
reply to e-mail messages as quickly as possible, usually within 72 hours (3
business days). If your problem requires more immediate attention or if you
have not heard from us within 3 days, please call our office at (734)
712-1000. |
| E-mail
messages should be used for non-urgent problems only. Please do not use
e-mail to notify us that you are experiencing a medical problem such as
pain, nausea, diarrhea, fever, shortness of breath, etc. |
| All
e-mail messages should include your full name, date of birth, e-mail address
and a telephone number where we can reach you during the day. Please give us
a general idea about the type message in the "subject line" of the
e-mail message (e.g., "work excuse"). You
must include your PIN on all correspondence! |
| If
you wish to schedule an appointment or request a prescription refill, please
use the appropriate forms. The forms can be accessed by clicking on the “Appointments”
and “Prescription Refills”
links on the home page. Please do not use e-mail for these services. |
| Our physicians do not respond to e-mail addressed to our Web site. Some of our physicians do communicate with patients via e-mail. You may discuss this with your physician. If he or she does use e-mail for this service, please discuss the kind of information that can be included and ask for the physician's personal e-mail address. If you wish to discuss your condition, ask questions about treatment options, etc., please make an appointment to see your physician in the office. |
I
have read the guidelines for Internet communications and agree to abide by them.
Please provide me with a PIN.
Signature:
___________________________________________
Printed
Name: ________________________________________
Date
of Birth: ____________________________ Today's Date:
______________________________
Please
bring this form to our office or mail it to: Ann Arbor Hematology Oncology Associates,
St. Joseph Mercy Cancer Care Center, Suite C-139, 5301 Huron River Drive, Ypsilanti,
MI 48197.
To
be filled in by our office:
Ann
Arbor Hematology Oncology Associates, P.C.
734-712-1000
Saint Joseph Mercy Cancer Center
aahoa@annarborhem-onc.com