ELECTRONIC INFORMATION CONSENT FORM

– Response to Enquiries and Complaints

Within NHS Lothian, we are working to improve and modernise communication methods with patientsand comply with the Patients Rights Act 2011 Secondary amendments by enabling e-mail communication with patients.

Currently, Health Boards cannot send clinical identification to patients or any other appropriate person via the general electronic e-mail servers. General e-mail servers are insufficiently protected and information sent can be diverted to addresses not intended by the sender and, therefore, cause a confidentiality breach. Health Board’s do not send clinical information via general e-mail links and have strict Policy’s in place to ensure that these routes are not utilised.

However, patients contact us through e-mail very frequently asking questions and enquiries or making complaints. If a general reply is sufficient we can respond via the e-mail system but, if the reply requires to contain specific patient information a letter is written and posted.

The Patient Rights Legislation Secondary Amendment will come into force on the 1st April 2012 and requests Health Boards to enable patients to communicate with Health Boards electronically.

This information is to ensure that you understand the risk of communicating in this way.

We would also like to contact you in confidence to ask about your experience of our services and in the future to invite you to access your electronic health record online when this service becomes available

Please choose whether to allow NHS Lothian to contact you for the purposes listed below. Please put a Xin the box or boxes you are giving your consent to.

I allow NHS Lothian to contact me via my home/mobile telephone/email to respond to my question, enquiry or complaint. I understand an accept the risk that sending clinical information by an un-secured internet address involves the risk that the information can be diverted/sent to other parties/become lost.

I allow NHS Lothian to contact me via my home/mobile telephone/email to ask me about my experience of the service I have received in NHS Lothian. I understand if I choose to respond to any queries this will be in confidence.

I allow NHS Lothian to contact me via my home/mobile telephone/email to invite me to participate in accessing my electronic health record online, when this service becomes available in the future.

A copy of your signed Consent Form will be available on request to the relevant NHS Complaints Manager and will not be kept in your Health Record. It will not be used for any other purpose than to answer you on this particular occasion. You may withdraw your consent at any time by informing us in writing or e-mail of your wish to do so. A letter should be addressed to the Complaints Manager at the Customer Relations and Feedback Team, 2nd Floor, Waverley Gate, 2-4 Waterloo Place, Edinburgh, EH1 3EGor by e-mail to the

Home Telephone Number ______

MobileTelephone Number ______

Email address______

CHI Number (if known)______

Print Name of PatientPatient Date of Birth

_

Patient/Parent/Guardian SignatureDate

Hospital Use Only□Consent details updated