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Patient Portal Consent

Patient Portal – Consent and Release Form

Physician Compassionate Care, LLC d/b/a “DocMJ” offers secure viewing and communication as a service to patients who wish to view parts of their records and communicate with DocMJ. Secure messaging can be a valuable communication tool but has certain risks. In order to manage these risks, we need to impose some conditions for participation. This consent is intended to inform you of these risks and the conditions of participation and confirm that you accept the risks and agree to the conditions of participation.

Protecting Your Private Information and Risks:

We take efforts to protect your privacy. However, keeping messages secure depends on two additional factors:

  1. the secure message must reach the correct email address, and
  2. only the correct individual (or someone authorized by that individual) must be able to have access to the message.

Only you can make sure these two factors are present. It is imperative that our practice has your correct e-mail address and that you inform us of any changes to your e-mail address. You are responsible for protecting yourself from unauthorized individuals learning your password. If you think someone has learned your password, you should promptly change it.

Types of Online Communication/Messaging:

Online communications should never be used for emergency communications or urgent requests. If you have an emergency or an urgent request, you should contact 911.

Billing Consent:

By providing my financial payment information, including credit card number, debt card number, or bank account information, I hereby irrevocably agree to pay all charges when due, or payment of any future amounts due in full, if I fail to make any required monthly payments required by any monthly payment plan. In addition, I agree to pay all costs and fees associated with collections or processing payment of any failed payments or failures to pay any amounts when due.

Patient Waiver:

In consideration for being allowed to use the patient portal, I release from all liability and waive my right to sue in any and all forums, Physician Compassionate Care, LLC d/b/a “DocMJ” and their parent, owner, affiliate, vendors, employees, officers, Members, and agents from any and all claims, including negligence, resulting in any way from my use of the patient portal or submitting information into the patient portal, including, but not limited to my person medical or financial information.

Patient Acknowledgement and Agreement:

I acknowledge that I have read and fully understand this consent and release form and the Policies and Procedures regarding the Patient Portal. I understand the risks associated with online communications between my physician’s office and me and consent to the conditions and release of all liability outlined herein. In addition, I agree to follow the instructions set forth herein, as well as any other instructions that my physician’s office may impose to communicate with patients via online communications. I understand and agree with the information that I have been provided and am aware I may refuse to disclose my email address and other information.

Acceptance be done, by the patient’s acceptance of care services by DocMJ, by utilizing the Patient Portal, or by any other manner of acceptance recognized by contract law or equity. This consent and release agreement shall remain in full force and effect notwithstanding the termination, cancellation, or natural expiration of any relationship between you and DocMJ.