Patient Portal Authorization Release Form

Advanced Pain and Neuromuscular Consultants of Brevard offers this secure, HIPPA compliant communication tool as a courtesy to our patients.  Please carefully read the following information.

Secure messaging can be a valuable communications tool, but certain precautions should be used to minimize risks.  This authorization and release form informs you of the facts and risks of using this web portal. 

This  web portal is a webpage that uses encryption to keep unauthorized persons from reading communications, information, or attachments.  Using the connection channel between your computer and the Web site, you can read, view, or send information on or from your computer.  Secure messages and information can only be read by someone who knows the right login name and password to log into the Portal site. 

This method of communication and viewing prevents unauthorized parties from being able to access or read messages while they are in transmission. However, no transmission system is perfect. We will do our best to maintain electronic security.  Your email address is confidential and protected information.  We will protect this information as we do all your medical and other personal information.  We will never purposefully share this information with any third party.

Keeping messages secure depends on two additional factors: the secure message must reach the correct email address, and only the correct individual (or someone authorized by that individual) must be able to have access to it. You are responsible for ensuring that we have your current email address and you agree to inform us immediately if it changes.  Protect your username and password information as you would protect your banking information. Safeguard this information so that only you or someone you authorize has access to this information.

This is an optional service.  Use of this Patient Portal is extended as a courtesy to allow enhanced communication between our patients and their doctor. Abuse of this courtesy will result in our discontinuing electronic communication with you.  We reserve the right to suspend or terminate this service at any time.  We will notify you as promptly as possible if this service is terminated.

Please be as concise as possible. If your communication contains too many issues or complex issues we will ask you to come in for an appointment to discuss your concerns and questions you may have. The Patient Portal is not designed to replace the face-to-face encounter. Rather, it is designed to supplement those encounters. Remember that all communications will be part of your medical record.

Do NOT use the Patient Portal for urgent messages. We will normally respond to non-urgent inquires within 24 hours but no later than 3 business days after receipt. If you have not heard from us within 3 business days, please call the office at (321) 729-8223 to check the status of your request.

To help insure the tunnel remains secure, we need to have your current private email address.  You must inform us if it ever changes.

Keep your portal user ID and password secure so only you, or someone authorized by you, can gain access to patient information.  If you think someone has learned your password, immediately go to the portal site and change it.

DO NOT USE THE PORTAL TO COMMUNICATE AN EMERGENCY OR URGENT PROBLEM, instead call 911, just as you would for any emergency.

You must agree to not hold Advanced Pain and Neuromuscular Consultants of Brevard or its staff liable for network infractions beyond their control.

By signing this agreement, you acknowledge that you understand the policies, procedures and risks, agree to comply with them, and all of your questions have been answered to your satisfaction. If you do not understand, or do not agree to comply with our policies and procedures, do not sign this agreement and do not request a username and password.