Adult Patients | WMC Patient Portal Proxy Form

Patient Portal Proxy Access Form for Adult Patients
Patient Name:*
Last, First, Middle Inital
Patient's Date of Birth*

MonthDayYear
Last 4 digits of Patients Social Security Number*
Address

Street Address

Street Address Line 2

CityState

Zip Code
Patient Home Phone:
Patient Work Phone:
Patient Mobile Phone:
PROXY INFORMATION

Please complete the next questions as best describes the proxy access requested. Please note that for all types of proxy access, the patient's chart will be access through the proxy's Patient Portal account.
Relationship of Proxy to Adult Patient is: Note: This section also applies to Emancipated Minors. Emancipated Minors must provide proof of emancipation.*

Adult to Adult (Age 18 and older) The patient must sign this form to provide authorization for release of their medical information to any of the above proxies via the WMC Patient Portal. Authorization for proxy access is valid until revoked by the patient.Legal Representative of Adult Patient. Adults who have a surrogate relationship withanother adult through a legal arrangement
Select the option below that best describes this Legal Representative Relationship:

Power of Attorney for Health Care (with current authority)HealthCare ProxyLegal Guardian (court order). If you are the legal guardian or you have a current authority under a durable power of attorney for healthcare for this patient, then this request must be accompanied by a copy of the legal paperwork verifying your authority to have access to the patient’s medical information (unless it is already on file). You must notify Williamson Medical Center immediately in case of any change in authority.Other
*Legal documentation can be provided to the hospital via fax to 615-435-5775. You may also submit documentation via secure email to PortalHelpDesk@williamsonhealth.org. Please note that if the email is not sent securely (i.e., unencrypted email), it may be intercepted and seen by others during transmission. By choosing to send information by unencrypted email, you accept these risks.
Proxy Name*
Last, First , Middle Initial
Proxy Date of Birth*

MonthDayYear
Proxy's Last 4 numbers of SSN:*
Proxy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Proxy Email*

Confirmation Emailexample@example.com
Proxy Phone:
Please enter a valid phone number.
Proxy Home Phone:
Please enter a valid phone number.
Mobile
Please enter a valid phone number.
Has the Proxy ever been a patient at Williamson Medical Center?

YesNoUnsure
Does the Proxy have an active WMC Patient Portal Account?

YesNoUnsure
Proxy Printed Name
Last, First, MI
PROXY SIGNATURE

Clear
PATIENT AUTHORIZATION

PATIENT:

I understand and agree that:
- I choose to designate the person named in this document as a proxy to my Williamson Medical Center patient portal, thereby allowing him/her acces to my protected health information. I authorize release of any information contained in my patient portal to my designated proxy. I understand that the medical information in the patient portal is obtained from my electronic medical record.
- Subject to Williamson Medical Center policies and procedures and the Terms and Conditions for adult patients, the proxy’s access will remain in effect unless and until Williamson Medical Center recieves a request for termination of proxy access or the patient expires.
- Participation in patient portal and designating a proxy is completely voluntary. I undersetand that I am not required to designate a patient portal proxy and I am not required to provide this authorization. I also undersetand that Williamson Medical Center does not condition any of my health care treatment, payment, or other services on whether I provide this authorization. However, I also understand that if I do not provide authorization, Wiliamson Medical Center may decline to provide access to my patient portal to my designated proxy.
- I understand that if I no longer want the proxy to have access to my patient portal, I may request that Williamson Medical Center revoke his/her proxy access.
Patient Printed Name
Patient Signature

Clear
*Signature is not required if the patient’s Legal Representative is requesting proxy access and has provided legal documentation.

Feel free to contact us if you have any questions or concerns: PortalHelpDesk@williamsonhealth.org or 615-435-5757
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Patient Portal Proxy Access Form for Adult Patients

PROXY INFORMATION