Under State and Federal law there are certain types of medical information that the parent or guardian of a minor patient age 14-17 may not view without consent of the minor patient. Because of these requirements, please complete this form to maintain or create a Patient Portal record for you and your teen.

The patient's chart will be accessed through the Proxy's Patient Portal account which requires an email account, please provide below.

* For non-biological representatives, please provide legal documentation to hospital or fax to 615-435-7430. This includes: Custody, adoption decree, Power of Attorney, Conservatorship, Guardianship, Department of Children's Services Letter for Foster Parents, etc. You may also submit documentation via secure email to PortalHelpDesk@williamsonhealth.org. Please note that email that is not sent securely (i.e., unencrypted email) may be intercepted and seen by others during transmission. By choosing to send information by unencrypted email, you accept these risks.

Individuals requesting access must have parental rights or legal guardianship rights.

I am the parent or legal representative of the teen named above and I request access to the child's information online through the Williamson Medical Center (WMC) patient portal. I understand the requirements and procedures for accessing the teen's information online through the WMC patient portal. I understand the teen will also have access to their own WMC patient portal account.  I understand that if the teen revokes thier WMC patient portal account, then my access will also be revoked.  All the information I have provided is correct, and I have rights to access the teen's information online through WMC patient portal. 

I request access to the WMC patient portal. I agree to allow the parent or legal representative name on Page 1 of this form to access my medical information in the WMC patient portal account. I understand that I may revoke this access any time, unless prohibited by law, by asking my healthcare provider to do so.

As the patient and a minor 14-17 years old (teen), I understand that:

• I will receive an email with information on how to open my WMC patient portal account;
• I must log in with my own user ID and password;
• To protect the privacy of my health information, I will not share my user ID or password with anyone;
• I agree to abide by the terms and conditions on the WMC patient portal site;
• When I turn 18 years old, access by my parent or legal representative will end;
• Williamson Health patient portal email alerts will be sent to the email address I have given above;
• If I have a WMC patient portal account, I must allow at least one parent or legal representative to have access to my WMC patient portal account. This means my parent or legal representative will see all information in my WMC patient portal account.
  
  

Optional: This form can also be used to grant access for a parent or legal representative of a teen who has a medical condition determined by the teen’s provider that prevents the teen from participating in making WMC patient portal access decisions. The provider may sign below to signify such a condition exists for this patient.

Please note:  If you would like to save a copy of this form, choose "Preview Form" below and you should have the option to download and/or save the form.