PATIENT ACKNOWLEDGEMENT AND AGREEMENT
I acknowledge that I have read and fully understand this consent form. I understand
the risks associated with online communication between Dr. Weakley and me, and consent to the conditions outlined herein. In addition, I agree to the instructions
as outlined, as well as any other instructions that Dr. Weakley may require for communication with her patients via online communication. I have had a chance to
ask any questions that I had and to receive answers. I have been proactive about
asking questions related to this consent agreement. My questions have been answered and I understand and agree with the information provided in the answers. Furthermore,
I agree that if my request for an Online Office Visit is granted, I will be billed a $25.00 Online Office Visit fee which will appear on my next statement.

Terms and Conditions
for use of
Online Office Visit

INSTRUCTIONS FOR USING ONLINE OFFICE VISIT
ONLINE OFFICE VISIT IS NOT TO BE USED FOR EMERGENCIES. If there is any chance at all that your condition could be considered urgent (i.e. shortness of breath, chest tightness, wheezing, acute coughing, chest pain, etc.), DO NOT USE this option. Call our office or 911 immediately.

As a general guideline, Online Office Visit requests will be responded to by the close of the next business day. If you feel you need a faster response, do not use this option. Call our office to schedule an appointment.

You agree to take steps to keep your online communications to and from me confidential, including:

• Do not store messages on your employer-provided computer; otherwise,
  personal information could be accessible or owned by your employer.
• Use screen savers or close your messages instead of leaving your messages
  on the screen for passersby to read.
• Keep your password safe and private.
• Do not allow other individuals or another third party access to the computer(s) where you store medical messages or other personal medical information.
• If you have, or learn of, any personal email addresses that I use, you will not
  use them for medical communications. Standard email lacks security and privacy features and may expose medical communications to employers or other
  unintended third parties.
• Withdrawal of this Informed Consent must be done by written online
  communications or in writing to my office.

Use good communication etiquette:

• Confirm that your name and other personal information in the message is correct.
• Review the message before sending it to make sure that it is clear and that all relevant information is included.

Update your contact information on the network as soon as it changes, including changes to your regularly used email address

CHARGES FOR USING ONLINE COMMUNICATIONS
My office may charge for certain online communications. You will be informed in advance when/if these charges apply and you will be responsible for payment of these charges if you accept and use any fee-based service. Currently, my fee for an Online Office Visit is $25.00.

You may choose to contact your insurance carrier to determine if they cover online communications. If you have verified that your insurance will pay for an Online Office Visit, please notify my billing staff and we will submit a claim to your carrier on your behalf. Please keep in mind that although your carrier may cover an Online Office Visit, they may still apply a co-pay, co-insurance and/or deductible to the claim. You will be responsible for any fees not covered by your insurance carrier.

CONDITIONS OF USING ONLINE COMMUNICATIONS
The following agreements and procedures relate to online communications:

• My office will print out a copy of all medically important online communication and include it in your medical record. This means that appropriate members of my staff will have access to these communications as part of our medical records keeping, treatment, and billing. My staff will comply fully with HIPAA Privacy Act regulations.
• I will not forward online communications with you to third parties except as authorized or required by law.
• You agree to follow my identity verification procedures in connection with online communications and you acknowledge that failure to comply with these procedures may terminate our online communications.
• Online communication will be used only for limited purposes. It cannot be used for emergencies or time-sensitive matters. It should be used with caution. It should not be used to communicate highly sensitive medical information. If there is other information that you don't want transmitted via online communications, you must tell me.
• I will make every attempt to respond within the timeframe I have designated. However, there may be times when this is not feasible and you understand and agree to accept variations in response times and use other forms of communications with my office and me if online responses are not satisfactory to you. Please note that online communication should never be used for emergency communications or urgent requests. These should occur via telephone or using existing emergency communications tools.
• While I will take reasonable precautions to protect your information, I am not liable for improper disclosure of confidential information unless it was caused by my intentional misconduct.
• Follow-up is your responsibility. You are responsible for scheduling any necessary appointments and for determining if an unanswered online communication wasn't received.
• You are responsible for taking steps to protect yourself from unauthorized use of online communication, such as keeping your password confidential. I am not responsible for breaches of confidentiality caused by you or an independent third party.
• I will not engage in any illegal online communication, including illegally practicing medicine across state lines.
• If, when answering an online communication, I advise you to schedule a face-to-face office visit and you fail to comply with that advice, you acknowledge that you accept full liability and responsibility for any adverse consequences arising from any failure to comply with said request on your part.

ACCESS TO ONLINE COMMUNICATIONS
The following pertains to access to, and use of, online communications:

• Online communication does not in any way diminish any of the ways in which you can communicate with or see me. It is an additional option and not a replacement. You are encouraged to contact my office via telephone, mail, or in person if you have any questions or needs.
• I alone will decide which medical topics are appropriate for online communication and with whom I communicate online.
• I may stop providing online communication with you or change my online services provided at any time without prior notification to you.

RISKS OF USING ONLINE COMMUNICATION
All medical communications carry some level of risk. While the likelihood of risks associated with the use of online communication, particularly in a secure environment, are substantially reduced, they are nonetheless real and very important to understand. It is very important that you consider these risks each time you plan to communicate with me and to ensure that you will communicate in such a fashion as to minimize the potential for any of these risks. These risks include, but are not limited to:

• Online communication may travel much further than you planned. It is easier for online communications to be forwarded, intercepted, or even changed without your knowledge.
• Online communication is easier to falsify than handwritten or signed hard copies. A dishonest person could attempt to impersonate you to try to get your medical records.
• It is harder to get rid of an online communication. Backup copies may exist on a computer or in cyberspace, even after both of us have deleted our copies.
• Online communication is not private simply because it relates to your own medical information. I use a secure network; however, keep in mind that employers and online services have a right to inspect and keep online communications transmitted through their system.

You agree to use the Online Office Visit service in good faith.

You acknowledge and agree that you will be solely responsible for any fee charged by my office. You agree that my fee, if any, will be charged to your patient account.

You agree that it is your responsibility to act in accordance with your health plan's regulations when using the Online Office Visit service. If you are unsure of your health plan's requirements, please contact your health plan directly.

CONSENT TO ELECTRONIC COMMUNICATIONS AND TRANSACTIONS
When you visit or use this site and the services associated with it, you are communicating with me (or my office) electronically. When you use the Online Office Visit service, you are transmitting personal health information electronically. I (or my office staff) will communicate with you by posting notices on this site or by sending you email. You consent to these methods of electronic communication. You and I each agree to electronically conduct the business and healthcare transactions, if any and as applicable, in which you engage. You agree that all agreements, notices, records, disclosures, and other communications that I (or my office staff) provide to you electronically satisfy all legal requirements that such communications be in writing.