Before you begin filling out this form, please be sure YOU AGREE AND CONSENT to these things:
1) SUBMITTING THIS FORM ELECTRONICALLY, AS WELL AS TYPING YOUR NAME AND CLICKING ON THE FINAL "SUBMIT" BUTTON AS YOUR ELECTRONIC SIGNATURE.
2) ENTERING YOUR EMAIL ADDRESS, AND RECEIVING A COPY OF ALL OF YOUR RESPONSES AT THAT EMAIL ADDRESS. This allows us to insure that we connect the responses to this form with a valid person and address on the other side.
IF YOU DO NOT AGREE TO THESE THINGS, please DO NOT CONTINUE filling out this form. You may access a printable copy of these documents at jhomd.com
By filling out this form and accepting the terms below, I recognize that electronic communication does not have any guarantee of privacy, and that a third party may be able to access my protected health information (PHI). However, due to the increased convenience offered by the use of methods such as online forms, email, text messages, and faxes, I consent to their use to transmit my PHI.
Should I wish to withdraw my consent at any time, I understand that I must notify James C Ho MD, or his staff in writing of the withdrawal of my consent.
I will choose an option below consistent with the methods of communication I prefer.
PLEASE CHOOSE AN OPTION BELOW:
I understand the risks of transmitting protected health information via non-secure methods and do hereby give permission to James Ho MD and his staff, to communicate with me and transmit my protected health information via non-secure means including, but not limited to, email, online forms, text messages, and faxes.
I DO NOT want my protected health information transmitted via email, online forms, text messages, or faxes. I understand this means that I will not be able to use the online scheduling system, nor will I be able to receive statements, bills, notes, documents, or appointment updates, reminders, or changes via email or text messages. I understand that ALL COMMUNICATION BETWEEN ME AND DR JAMES HO AND HIS STAFF WILL OCCUR OVER THE PHONE, IN PERSON, OR BY THE PHYSICAL (POSTAL) MAIL SYSTEM. I also understand that, at a future date, if I communicate with Dr James Ho and his staff via email or text message that I am waiving my right to methods of secure communication and am choosing OPTION 1, above.