07/25/2014 04:16am MSH 2122418866 #149 Page 02/06 .M IR it r.F ner•Trwr.rr. r Mount Faculty Practice Doctors CONSENT FOR COMMUNICATION VIA E-MAIL (Provider-Patient) 1, -SiairFilleV eparei4 , hereby consent to have my physician, . , communicate with. me or members of his/her staff, where appropriate or other physicians, nurse practitioners and pharmacists via e-mail regarding the following aspects of my medical care and treatment: [test results, prescriptions, appointments, bailing, etc.]. I understand that e-mail is not a confidential method of communication. I further understand that there is a risk that e mail communications between my physician and me or members of my physician's office staff or between. my physician and other physicians, nurse practitioners and pharmacists regarding my medical care and treatment may be intercepted by third parties or transmitted to' unintended parties. I also understand that any e-mail communications between my physician and me or members of his/her office staff, or between my physician and other physicians, nurse practitioners or pharmacists regarding'my medical care and treatment will be printed out.and made a part of my medical record. I understand that in an urgent or emergent situation I should call my provider or go to the Emergency Room and not rely on e-mail. 8 mail: _ jeeVaCOCHOnZ TY)661- Wrn Date; a_01* signature: EFTA01199449