Consent to Communicate Health Information by Email and Text Message

You agree Duval Medical, P.A., all members of its affiliated covered entity, and

Fountain Vitality Inc. (collectively “Fountain”) will communicate with you by unencrypted

email and text (SMS) message related to your health care and services you receive at Fountain,

including medications you are prescribed, tests and test results, treatment and diagnostic

information, appointment reminders, and other health care related purposes. This form provides

information about the risks of these forms of communication and guidelines for email/text

communication. It also will be used to document your consent for communication with you by

email and text message and your understanding of the information provided in this consent.

1. Risk of using unencrypted email and text messages: Fountain will use reasonable means to

maintain, security and confidentiality of email/text information sent and received. However,

the use of unencrypted email and text message has a number of risks that you should consider,

including, but not limited to, the following:

• There is a risk the information could be read by anyone accessing your text messages or emails or intercepted by third parties in transmission.

• Mobile devices containing emails and texts can be lost or stolen resulting in disclosure of messages to unauthorized individuals.

• Senders can misaddress an email or text and send the information to an undesired recipient.

• Backup copies of emails and texts may exist even after the sender and/or the recipient has deleted their copy.

• Employers and third parties have a right to inspect emails and texts sent through their systems.

• Emails and texts can be obtained and used as evidence in court.

2. Conditions for the use of email and text messages: You acknowledge and consent to the

following conditions:

• IN A MEDICAL EMERGENCY, DO NOT USE EMAIL, CALL 911. Do not use email/text for urgent problems.

• Emails/texts to us should not be time-sensitive. While we try to respond timely, we cannot guarantee that any particular email or text will be read and responded to within any particular period of time. If you have not heard back from us within three days, call us to confirm that we have received your email or text. It is your responsibility to follow up with your Fountain medical providers if warranted.

• You should use your best judgment when considering the use of email or text messages for communication of sensitive medical information. Consider speaking with your medical providers at Fountain to discuss complex and/or sensitive situations rather than sending email or text messages regarding such situations.

• Fountain and its personnel are not responsible for the content of messages you sent to Fountain, or breaches of confidentiality caused by you or any third party.

• You understand that message and data rates from your cell phone service provider may apply.