Patient Consent for Limited Email and Text Communications

The Karen Horney Clinic can use email or texting to respond to routine questions and scheduling of appointments. By signing the Policies & Services Agreement, you are stating understanding and agreement that:

• No assurances or guarantees have been made that any public personal e-mail or text message will remain confidential.
• Email and text messages may be viewed by designated members of the Clinic staff who require it to perform their specific job function.
• Non-secure email information received at either my home or place of employment can be accessed by third parties.
• The Clinic will not always be available to answer email or text. I understand that I may not receive a response for several hours or even days. No responses will be made after 9:00 p.m. on weekdays, or will have limited access on weekends or holidays. If I require an immediate response to a question or have an emergency condition, I will not use email or text to communicate to Clinic staff.
• Clinic staff will not answer complex questions received by email or text. Clinic staff will not give medical advice using email or text. I must schedule an appointment to answer such questions.
• The use of email and text is restricted to certain types of confidential medical information. Information which must not be relayed by email includes, but not limited to: HIV/AIDS related treatment, sex related treatment, psychiatric treatment, substance abuse treatment, test results, and request for release records. Information of this nature must be relayed only by telephone, letter, or in person.
• Written requests for records may not be submitted via email or text. They can be submitted on this website at https://www.karenhorneyclinic.org/consent-form/
• The Clinic will not release the contents of any email or text correspondence without my express written permission except as permitted or required by law. I am further aware that if I wish email or text concerning me/the patient be sent to a designated person, I must request this in writing and by filling out a consent form.

I have read and understand the above. I agree to abide by the above guidelines and restrictions. I have been given an opportunity to ask questions by calling 212-838-4333 or speaking directly to Clinic staff at the time of my appointment. *

• Check here to agree.

Communication Method: Text, Email or Both: *EmailTextBoth

Enter email address: *

Enter phone number for texts *

Signature *

Date: *

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