Electronic Signature Consent & Disclosure
Electronic Signature Consent
You have been requested to electronically sign a document in PatientIQ by the Requesting Party. As an Authorized Signer, you must comply with the rules and regulations governing “electronic signatures” as set forth in 21 C.F.R. Part 11, as amended, and in connection therewith, each Authorized Signer hereby understands, acknowledges and represents that:
- electronic signatures will be used in PatientIQ;
- electronically signing and submitting any document(s) to PatientIQ legally binds me in the same manner as if I had signed the document in a non-electronic form;
- the electronically stored copy of my signature, any written instruction, reason for signing, authorization and any other document provided to me by PatientIQ, is considered to be the true, accurate and complete record, legally enforceable in any proceeding to the same extent as if such documents were originally generated and maintained in printed form;
- I agree not to contest the admissibility or enforceability of PatientIQ’ electronically signed documents;
- any loss, theft or other compromise, or suspected compromise, of your PatientIQ Account or unique password must be immediately reported to PatientIQ at email@example.com; and
- any known or reasonably suspected violation any applicable law, rule or regulation, including without limitation 21 C.F.R. Part 11, must be immediately reported to PatientIQ
Electronic Signature Disclosure
From time to time, the Requesting Party (if you are a patient: the healthcare organization requesting your signature and listed under your PatientIQ Account; and if you are an Authorized User: your employer and/or the organization that is a PatientIQ customer that authorizes your use of PatientIQ) may be required by law to provide to you certain written notices or disclosures. Described below are the terms and conditions for providing to you such notices and disclosures electronically through the PatientIQ electronic signing system (PatientIQ eSign). Please read the information below carefully and thoroughly, and if you can access this information electronically to your satisfaction and agree to these terms and conditions, please confirm your agreement by clicking the "I agree" button when prompted in the software.
Getting Paper Copies
At any time, you may request a paper copy of any document made available to you electronically in PatientIQ by contacting the Requesting Party directly. The contact information for the Requesting Party will be displayed in your PatientIQ account. In PatientIQ, you will have the ability to download and print documents we send to you during the signing session and, if you elect to create a PatientIQ account, you may access your historical documents in your account settings. If you have any questions or are experiencing a technical difficulty please reach out to us at firstname.lastname@example.org. Otherwise, please contact the Requesting Party directly for paper documents or any questions about those documents.
Withdrawing Your Consent
If you do not wish to receive documents, notices, and disclosures from us electronically, please notify the Requesting Party. Unless you notify the Requesting Party, all documents, notices, and disclosures will be sent to you electronically. If you do not wish to sign a document electronically, select the "Decline to Sign" option.
How to Contact the Requesting Party:
Under your PatientIQ account, you will see contact information for the healthcare organization that is requesting documents from you. Please reach out to the Requesting Party directly if you have questions about the contents of the document, wish to receive a paper copy, or do not wish to be contacted in the future.
How to Advise the Requesting Party of your New Email Address:
Please update your email address in your PatientIQ account. You may also notify the Requesting Party directly.
Required Hardware and Software
- Operating Systems: Windows XP/Vista/8/10, Mac OS X
- Browsers: Google Chrome, Internet Explorer, Safara (Mac only)
- PDF Reader: Acrobat or similar software to view PDFs
Note: this minimum requirements are subject to change.