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.

EASY PRINTABLE VERSION

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:

Your personal identification number (PIN) is _____________________ . Please include this number in all Internet correspondence with our office.

Ann Arbor Hematology Oncology Associates, P.C.
734-712-1000
Saint Joseph Mercy Cancer Center
Ypsilanti, Michigan
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