Healthcare Patient Portal Addition

Healthcare Patient Portal Addition

Patient Information

Patient Name:

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History (summary)

Portal Account Details & Access Requested

Desired Username:

Select access privileges requested (check all that apply):

View medical records and visit summaries
Secure messaging with care team
Receive laboratory and diagnostic results
Appointment requests and scheduling

Proxy / Caregiver Access

I request proxy access for a designated caregiver: Yes

Communications & Electronic Consent

I authorize the practice to communicate with me electronically for purposes of appointment reminders, test results, and routine non-urgent clinical communications. I understand that electronic communication may carry a risk of unauthorized access. I accept responsibility for maintaining the confidentiality of my portal credentials and for notifying the practice immediately if my access credentials are compromised or if I wish to revoke authorization.

Preferred electronic communications (check all that apply):
Email
SMS / Text message
Secure portal messages

Authorization, Limitations, and Acknowledgments

By signing below I hereby request enrollment in the patient portal and authorize the practice to create or modify portal access in accordance with the privileges I have indicated. I understand that:

1. Portal access may include sensitive health information. I accept the responsibility to protect my username and password and to log out after each session on shared devices.
2. The practice may limit or revoke access for security, legal, or administrative reasons; revocation will be communicated when feasible.
3. Electronic messaging is not for urgent or emergency communications. I will contact emergency services or call the clinic directly for urgent matters.
4. Proxy access grants the designated individual access to my health information to the degree specified and may be revoked by me at any time in writing.
5. This authorization remains in effect until revoked in writing or on the expiration date below, whichever occurs first.

I certify that the information provided on this form is true and correct to the best of my knowledge. I understand that providing false information may be grounds for denial or termination of portal access and may subject me to applicable legal or administrative actions.

Patient Identifiers

Sign Now