By signing this authorization, I understand that I am requesting Frances Mahon Deaconess Hospital to revoke the above-named proxy from being able to access my patient portal. I understand that this revokes my Proxy online access to my personal health information. My Proxy will no loner be able to view information contained within my Patient Portal or third-party app that I am able to view.
The previously signed authorization granting Proxy Access is no longer valid and is revoked by me. I understand that this written request is necessary to revoke or cancel this authorization. I understand that revocation will not be effective immediately but may take up to 3 business days. I realize that the information used and/or disclosed prior to this revocation may be subject to re-disclosure and no longer protected by federal or Montana State privacy laws. I, in no way hold Frances Mahon Deaconess Hospital responsible for any information obtained by this proxy prior to revoking authorization.
I understand that my protected health information (PHI) will be moved from JotForm to Microsoft OneDrive temporarily for operational workflow where access is limited to authorized staff only. Both JotForm and OneDrive are HIPAA compliant. For questions about PHI, please contact FMDH Privacy Officer at 406-228-3547.