Healthcare eHealth Application

Healthcare eHealth Application

Patient Information

Date of birth:    Gender: Female Male Other / Prefer not to say

Emergency Contact

Insurance Information

Medical History

eHealth Portal Access Requested

I request access to the provider electronic health portal with the following privileges (select all that apply):

View clinical records, visit summaries, and test results
Secure messaging with clinicians and staff
View billing statements and insurance information
Request medication refills and appointments

Proxy / delegate access requested: Yes    If yes, specify delegate name and relationship below.

Requested delegate access expiration (if applicable):

Electronic Communication Consent

I authorize the healthcare provider and its staff to communicate with me electronically regarding my health information, appointments, test results, treatment instructions, and billing. I understand that electronic communications may include unencrypted messages and that there is a risk of unauthorized access. I accept responsibility for maintaining the confidentiality of my account credentials and for notifying the provider immediately if I suspect unauthorized access.

Preferred communication methods (select all that apply):

Email to address on file
SMS / text messages to mobile phone
Secure portal messages only

By checking the box below I give permission to receive electronic communications as described above and accept responsibility for access and use of the portal.

I consent to receive electronic communications and portal access

Privacy, Security, and HIPAA Acknowledgment

I acknowledge that I have been provided the provider's Notice of Privacy Practices explaining how my protected health information may be used and disclosed. I understand that portal use may permit access to my protected health information and that the provider will take reasonable steps to secure electronic communications, but cannot guarantee absolute confidentiality.

I acknowledge receipt of the Notice of Privacy Practices and understand the security limitations of electronic communications

Authorization, Termination, and Applicant Certification

Authorization: I authorize the healthcare provider to create an electronic health portal account for me and, if requested above, for my delegate. This authorization permits access to the categories of information and communication methods selected on this application. I understand my account may be suspended or terminated for misuse, and that access may be revoked by submitting a written request to the provider.

I certify under penalty of perjury that the information provided on this application is true and correct to the best of my knowledge. I understand that falsification of information may result in denial or revocation of portal access.

Effective date of this authorization:    Authorization expiration date:

Withdrawal of authorization: I understand I may withdraw this authorization at any time by providing written notice and that withdrawal will not affect actions taken in reliance on this authorization prior to receipt of withdrawal.

I have read and agree to the terms, conditions, and responsibilities set forth in this application

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