Patient Information and Acknowledgement Form

PLEASE READ THE FOLLOWING INFORMATION CAREFULLY. YOUR CONTINUED USE OF THIS SITE AND RELATED SERVICES WILL INDICATE YOUR UNDERSTANDING OF THIS INFORMATION, YOUR AGREEMENT THAT YOU WILL FOLLOW ALL INSTRUCTIONS GIVEN, AND YOUR ACCEPTANCE OF THE RISKS AND TERMS OUTLINED BELOW. IF YOU DO NOT AGREE TO BE BOUND BY THESE TERMS PLEASE PROMPTLY EXIT THIS SITE.

Risks of Using Electronic Communication Systems. Moffitt Cancer Center offers patients the opportunity to use the MyMoffitt Patient Portal website to view general information, to view certain personalized information, to conduct selected transactions (e.g., pay a bill), and to limited communication by secure messaging and e-mail (e.g. make an appointment).

Secure messaging is online electronic communication that takes place between various authorized parties within a secure website. Messages are sent, received and archived through the website, and internet email is not required or used. Security and privacy are provided through encryption, the special digital encoding of data that can prevent unauthorized persons from reading the contents of protected messages. (Internet email is usually not encrypted and therefore is inherently not secure.) Moffitt Cancer Center is using industry-standard encryption technologies to protect and secure the MyMoffitt Patient Portal website, including the secure messaging function.

However, the use of any electronic communication system such as the World Wide Web (including secure messaging) has a number of risks that patients should consider before use. Many of these risks apply to the use of electronic information in general; other risks apply particularly to email communications. These include, but are not limited to, the following risks:

  • Electronic communications, including email can be copied, circulated, forwarded, stored, and can be accidentally or intentionally immediately broadcast worldwide and received by many unintended recipients.
  • Electronic communications, including email, are easier to falsify than handwritten or signed documents.
  • Backup copies of electronic communications, including email, may exist even after the originator or recipient has deleted his or her own copy.
  • Employers and online services have a right to archive and inspect emails transmitted through their systems.
  • Electronic communications, including email, are discoverable and can be used as evidence in court.
  • Passwords providing access to electronic communications, including Internet Service Provider accounts for email, can be stolen and misused, or host systems can be compromised, leading to unauthorized disclosure of personal information.
  • Email senders can easily misaddress an email.
  • Email can be intercepted, altered, forwarded or used without written authorization or detection.
  • Email can be used to introduce viruses into computer systems.
  • Electronic communications, including email, can be misinterpreted.
  • Electronic communications, including email, may not be answered in the time frame expected by the sender.

Conditions for the Use of Electronic Communication Systems
Moffitt Cancer Center will use reasonable means to protect the security and confidentiality of electronic information sent and received, including the use of encryption and other security technologies. However, because of the risks outlined above, Moffitt Cancer Center cannot guarantee the security and confidentiality of web-based communications, and will not be liable for improper disclosure of confidential information that is not caused by Moffitt Cancer Center's intentional misconduct.

It is also important to understand that MyMoffitt Patient Portal is not intended to replace or to substitute for face-to-face meetings and/or personal interaction and conversations with your health care team.

Therefore, you must agree to and acknowledge the following terms when using electronic communications systems, including MyMoffitt Patient Portal to communicate and share information with Moffitt Cancer Center.

  • I understand that electronic communications will be read and responded to as promptly as possible; however, a specific turnaround time is not guaranteed. Therefore, I will not use electronic communications for medical emergencies or other time-sensitive matters.
  • I acknowledge that some or all electronically transmitted information concerning my diagnosis and/or treatment may be made part of my medical record , and that it is up to my health care team to decide when this will happen.
  • I am aware that my electronic information may be forwarded internally to other Moffitt Cancer Center staff and agents of Moffitt Cancer Center as necessary for diagnosis, treatment, reimbursement and other business purposes. Electronic information will not, however, be forwarded to independent third parties without my written consent, except as authorized or required by law.
  • I understand that it is my responsibility to protect passwords or other means of access to electronic information. It is also understood that Moffitt Cancer Center and its representatives are not liable for breaches of confidentiality caused by any third party or myself.
  • I acknowledge that it is my responsibility to follow up and/or schedule an appointment if warranted.
  • I acknowledge that it is my responsibility to read and appropriately follow all communications sent to me by Moffitt Cancer Center representatives and to follow up with a person to whom I have sent a secure message or email if I have not received a response in a time frame that is acceptable to me.
  • I acknowledge that it is my responsibility to provide Moffitt Cancer Center with accurate information about me, and that my health care team at Moffitt Cancer Center will use some or all of the information I provide, as they see fit, to make decisions about my diagnosis and treatment.
  • I acknowledge that it is my responsibility to keep Moffitt Cancer Center abreast of my treatment.
  • I understand and acknowledge that I may not receive a response from my health care team each time I communicate with them via electronic communication systems; it is up to them to decide whether and when to send me a response.
  • I acknowledge that neither MyMoffitt Patient Portal/My Survivorship nor any other use of Moffitt Cancer Center?s website is a substitute for appropriate and timely contact with my health care team.
  • I understand and acknowledge that I may not transmit any viruses, time bombs, Trojan horses, worms, surveillance codes, or other computer programming routines, and that I may not do anything that would damage any data or information on MyMoffitt Patient Portal.
  • I acknowledge that Moffitt Cancer Center may discontinue this service at any time.
  • I acknowledge that I will follow the instructions listed below, and other instructions that I may receive from Moffitt Cancer Center from time to time. I agree that I will:
    • Use secure messaging or email only to send messages regarding the following categories:
      • care information
      • clarification of patient instructions
      • information related to clinical trials
      • prescription re-fills
      • scheduling requests for follow-up clinic visits
      • billing and insurance questions.
    • Include key words relating to the subject of the communication in the electronic message's subject line.
    • Avoid or minimize use of computers widely accessible by others, such as an employer's computer.
    • Keep electronic messages short.
    • Review the electronic message before I send it to make sure it is clear and that all relevant information is provided.
    • Review any email message before I send it to make sure that the "TO" field is properly completed.
    • Acknowledge receipt of an electronic message from Moffitt Cancer Center by sending a brief reply.
    • Take precautions to preserve the confidentiality of secure messages and email.
    • Not use secure messaging or email to transmit information or questions of an urgent nature, and in an emergency I will go to an Emergency Room and/or contact my health care team as I have been instructed in the past.

Patient Acknowledgement and Agreement
I acknowledge that I have read and fully understand the information provided in this form. I understand the risks associated with using electronic systems to contact and receive information from Moffitt Cancer Center. I agree to the terms listed above, in addition to all the terms and conditions of the Moffitt Cancer Center Legal Statements, including the Terms of Use and Privacy Policy. In addition, I agree to the instructions outlined herein, as well as any other instructions that any Moffitt Cancer Center representatives may create pertaining to electronic communications between Moffitt Cancer Center and its patients. I understand that Moffitt Cancer Center may discontinue this service at any time. Any questions I may have had were answered.