Rittenhouse Women's Wellness Center

Available Forms

A.) Internal Medicine Authorization to Release Healthcare Information A.) Internal Medicine Health History Form A.) Internal Medicine HIPAA : Notice of Privacy Practices A.) Patient Registration B.) Dermacenter Client Information and History C.) Nutrition 3 Day Food Diary C.) Nutrition History D.) Dr. Perilstein: Emotional Well-being Authorization to Release Protected Health Information D.) Dr. Perilstein: Emotional Wellbeing Consent for Treatment D.) Dr. Perilstein: Emotional Wellbeing Receipt of Privacy Information E.) Dr. Liggera's Patient Registration Form F.) Payment and Cancellation Policy G.) Email Agreement

G.) Email Agreement

E-mail offers an easy and convenient way for patients and doctors to communicate. In many circumstances, it has advantages over office visits or telephone calls. But remember: there are important differences. E-mail is not the same as calling our office; there is no person at the other end of the call; just a computer. You cannot tell for certain when your message will be read, or even if your doctor is in the office or on vacation. Nonetheless, we believe that the ease of communication e-mail affords is a benefit to patient care. It will further assist us if you could identify the nature of your request in the subject line of your message. Below are our rules for contacting us using e-mail. 1. E-mail is never, ever, appropriate for urgent or emergency problems! Please use the telephone or go to the Emergency Department for emergencies. 2. E-mail is great for asking those little questions that do not require a lot of discussion. Appropriate uses of e-mail also include prescription refill requests, referral and appointment scheduling requests and billing/insurance questions. 3. E-mails should not be used to communicate sensitive medical information, such as information regarding sexually transmitted diseases, AIDS/HIV, mental health, developmental disability, or substance abuse. 4. E-mail is not confidential. It is like sending a postcard through the mail. My staff may read your e-mails to handle routine, non-clinical matters. You should also know that if sending e-mails from work, your employer has a legal right to read your e-mail if he or she chooses. 5. E-mail may become a part of the medical record when we use it; a copy may be printed and put in your chart. 6. E-mail is not a substitute for seeing me. If you think that you might need to be seen, please call and book an appointment! 7. E-mails may be forwarded to my staff for handling, if appropriate.

Finally, either one of us can revoke permission to use the e-mail system at any time. *

I DO want to communicate with my doctor electronically. I have read the above information and understand the limitations of security on information transmitted. I understand that my doctor may not be able to communicate with me electronically about my specific condition if I live outside of the state in which my doctor is licensed.

I Do NOT want to communicate with my doctor electronically.

Patient Signature *

Email Address *

Date *

State of Residence *

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