Purpose of the Informed consent form
Tricity Family Medicine & Urgent Care Clinic, PLLC offers a secure way for you to view parts of your medical records upon request, view normal laboratory results, update personal information, send secure HIPAA compliant messages to staff and receive clinical summaries. Secure patient portals do have certain risks. In order to manage these risks, there are certain conditions of participation. This form’s intention is to document that you have been informed of these risks and the conditions of participation and that you accept the risks and conditions of participation.
How to participate in the patient portal
The patient portal occurs via a website hosted by our electronic health record system. Once you agree to and sign, you will be sent a welcome e-mail which will give you a user name and password to sign in. Because of the security of the website, all information passing between the EHR and your computer is encrypted so that it remains secure. The patient portal can be accessed through our website www.tricityfamily.com
Protecting your private health information and risks
The security of the patient portal requires two things: the correct e-mail address and the correct person (or person authorized by that individual) having access to the e-mail. These two factors are the responsibility of the patient. Please
notify our office or the patient portal any time you change your e-mail address. You must also be very careful to keep
track of who has access to your e-mail account so only you or someone designated by you can view your portal
messages. If you have any concern that someone else has your password, contact our office and we will issue you a
new password. We understand the importance of privacy in patient care and will continue to strive to make all
information as confidential as possible. We will never sell or give away any private information, including your e-mail
address.
Conditions of participation in the portal
Access to and participation in the portal is optional and does not affect the care you will receive at Tricity Family Medicine & Urgent Care Clinic, PLLC. Therefore, we reserve the right to suspend or terminate this service at any time or
for any reason. If we do terminate this service, we will notify you as promptly as possible. You also agree to not hold
Tricity Family Medicine & Urgent Care Clinic, PLLC or any of its staff liable for any network infractions beyond its control.
By signing below, you acknowledge that you have read this consent form and that you understand and will comply with
it.