Signature Page with E-mail Policy
1. I have read the information about e-mail procedures and privacy and have received answers to all of my questions about using e-mail to communicate with Dr. Emily Queenan.
2. I understand that e-mail is never appropriate for urgent or emergency situations.
3. I understand that e-mails sent to Dr. Queenan from any email address, other than a Onebox email address, are considered insecure and I assume all responsibility for any misuse or misdirection of personal health information contained in such e-mails.
4. I have read the Office Policies of Queenan Family Medicine and Maternity Care and have received answers to all of my questions regarding the contents therein.
5. I have read the Notice of Privacy Practice for Protected Health Information (above) of Dr. Emily Queenan and have had all of my questions answered regarding the contents therein.
Signature: _______________________________________ Date: __________________
Print Name: _____________________________________________________________
Date of Birth: ________________________