Healthcare WebCOC Account

HEALTHCARE WEBCOC ACCOUNT REQUEST AND AUTHORIZATION

Patient / Account Holder Information

Patient Name:

Emergency Contact

Insurance & Subscriber Information (if applicable)

Medical Information (Optional for Account Setup)

Account Request Details

Requested Account Type: Patient Portal (access to Continuity of Care documents) Proxy / Caregiver Access Emergency Access Only

Medical History and Problem List Medication List and Allergies Lab Results and Reports Visit Summaries and Continuity of Care Documents

Authorization for Release and Electronic Access

I authorize the release and electronic delivery of my Continuity of Care documents, medical records, and related clinical information to the WebCOC account established under this request. I understand that information released may include diagnoses, laboratory results, medications, allergies, and encounter summaries. This authorization permits access to current and past records to the extent described in the scope of access requested above.

I acknowledge that electronic transmission and online access present privacy and security risks, including potential access by unauthorized third parties if my account credentials are compromised. I accept these risks and agree to protect my account credential information. I will notify the health organization promptly upon learning of any suspected unauthorized access.

This authorization does not permit release of psychotherapy notes or substance use disorder treatment records protected by special federal or state confidentiality laws unless specifically indicated below.

Special Authorization (check any that apply): Include Psychotherapy Notes Include Substance Use Disorder Records (if permitted by law)

HIPAA Acknowledgment & Patient Rights

By signing below I acknowledge that I have been provided with the organization’s Notice of Privacy Practices and that I understand my right to revoke this authorization at any time by submitting a written revocation. I understand that revocation will not affect disclosures already made in reliance on this authorization prior to receipt of the revocation.

I understand that refusal to sign this authorization will not affect my ability to obtain treatment, payment, enrollment, or eligibility for benefits, except where allowed by law. I further understand that information disclosed as a result of this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy rules.

Security, Use Agreement, and Responsibilities

Account holder responsibilities:

1. Maintain confidentiality of usernames and passwords; do not share credentials.
2. Notify the health organization immediately upon any suspected breach or unauthorized access.
3. Comply with all applicable policies governing use of electronic medical records and data access.
4. Use information obtained only for lawful personal health management or for authorized caregiving purposes.

The organization reserves the right to suspend or terminate access where there is suspected misuse, security breach, or where access is no longer appropriate. The organization is not liable for third-party interception of data outside its direct control.

Attestation & Certification

By signing this form I certify, under penalty of perjury, that the information provided is true and correct to the best of my knowledge, that I am the patient or am authorized to act on the patient’s behalf, and that I consent to the disclosures described herein. I understand that providing false information may result in denial, termination of account access, or other legal consequences.

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