Healthcare Patient Portal Auth Form

HEALTHCARE PATIENT PORTAL AUTHORIZATION

This Patient Portal Authorization permits secure electronic access to selected portions of the patient's health information and communications through the provider's electronic patient portal. By completing and signing this form the patient or authorized representative authorizes access consistent with the scope and duration described below and acknowledges the terms, conditions and limitations set forth herein.

Patient Information

Insurance Information

Medical History (summary)

Portal Access Requested (select all that apply)

View medical records, test results and visit summaries

Secure messaging with providers and staff

Schedule, confirm or cancel appointments

Request prescription refills

View billing statements and pay bills

Proxy access for another person (complete proxy section below)

Scope, Duration and Revocation

This authorization applies only to the functions and information selected above. Access does not permit the proxy or designee to undertake actions beyond those functions. The authorization will remain in effect until:

Expiration date:    Or check if no fixed expiration: No fixed expiration; valid until revoked

This authorization may be revoked at any time by submitting a signed written notice to the health care provider. Revocation will not affect actions taken in reliance on this authorization prior to receipt of the revocation.

Electronic Communications & Security

I consent to receiving electronic communications related to my care, including appointment reminders, test results and secure messages through the portal. I understand electronic communications may be intercepted and that the provider will use reasonable safeguards but cannot guarantee confidentiality of transmissions outside the portal.

Preferred contact email:    Mobile phone for SMS (if consenting):

Consent for email communications: I consent    Consent for SMS/text: I consent

I acknowledge that I am responsible for selecting a secure password for portal access and for protecting my login credentials from unauthorized use. I agree to notify the provider immediately if I suspect unauthorized access.

HIPAA Acknowledgment

I acknowledge that I have been provided with the provider's Notice of Privacy Practices which describes how my medical information may be used and disclosed. I understand that this Patient Portal Authorization permits certain electronic disclosures and that such disclosures are subject to the terms of the Privacy Practice.

Acknowledgment: I acknowledge receipt of the Notice of Privacy Practices

Limitations, Fees and Legal Terms

The provider will not be liable for delays, interruptions, or failures in electronic communications that are outside the provider's reasonable control. The provider may apply reasonable administrative fees for certain portal services; such fees will be disclosed in advance where applicable.

I understand that information available through the portal may be a partial record and should not replace direct communication with my health care providers in an emergency or urgent situation.

Certification

By signing below I certify under penalty of perjury that I am the patient named above or the patient's duly authorized representative, that the information provided on this form is true and correct, and that I authorize access consistent with the selections made on this form.

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