Healthcare PHI Portal User Form

HEALTHCARE PHI PORTAL USER FORM

Use this form to request creation, modification, or termination of access to the healthcare provider's electronic patient portal and associated protected health information (PHI). Patient Name: Date of Birth: Medical Record Number:

Patient Information

Male   Female   Non-binary   Decline to state

Email   Phone   Text message

Emergency Contact

Insurance Information

Medical History (for clinician reference)

Portal Access Requested

View only (review clinical information)   View and send messages to provider   Request electronic transmission of records   Full access including appointments and billing

Laboratory results   Radiology/imaging reports   Clinical progress notes   Billing and account statements   Medication lists   Immunization records

Patient (self)   Authorized representative (complete representative section below)

Authorization and Legal Notices

By signing below, I authorize the healthcare provider to create, modify, or terminate a patient portal account that will permit access to the categories of PHI indicated above. I understand that:

1. This authorization permits access to PHI necessary to accomplish the requested functions and does not alter any separate authorizations required for release of psychotherapy notes or other specially protected information. I understand that certain records may require additional written authorization.

2. I consent to receiving electronic communications related to my care and this portal account, including appointment reminders, test results, and billing statements via the contact methods selected. Electronic communications may be intercepted or misdirected; I accept the confidentiality risks inherent in electronic delivery.

3. I am responsible for maintaining the confidentiality of my account credentials. I agree to notify the provider promptly if I suspect unauthorized access. The provider may suspend or terminate access if there is reason to believe account security has been compromised or terms of use are violated.

4. This authorization will remain in effect until the earlier of: (a) the expiration date specified below; (b) written revocation delivered to the medical records department; or (c) termination by the provider consistent with policy. Revocation is not effective to the extent that actions have already been taken in reliance on this authorization.

I acknowledge that I have received or been offered a copy of the provider's Notice of Privacy Practices that describes how my health information may be used and disclosed. I understand my rights to inspect and obtain copies of my health information and to request restrictions on certain uses and disclosures.

I certify that the information provided on this form is true and accurate to the best of my knowledge. I understand that knowingly making false statements on this form may subject me to civil or criminal penalties under applicable law.

Electronic Signature Consent: Selecting the signature box below or signing electronically constitutes my signature and verifies my identity for purposes of this authorization and agrees that this authorization may be maintained in electronic form.

I acknowledge and agree: I acknowledge receipt of the Notice of Privacy Practices and consent to portal access as indicated above.

Acknowledgment of Risk and Responsibilities

I understand that electronic systems are not error-free. I accept responsibility for verifying the accuracy of information received and for contacting my care team directly for urgent or emergent matters rather than relying solely on portal communications.

I agree to the terms above and authorize the creation or modification of the portal account as requested.

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