Adult Patients | WMC Patient Portal Proxy Form

Patient Name:*

Last, First, Middle Inital

Patient's Date of Birth*

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:

Relationship of Proxy to Adult Patient is:*

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

Proxy Name*

Last, First , Middle Initial

Proxy Date of Birth*

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 Work 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

PATIENT AUTHORIZATION

PATIENT: {patientName}

I understand and agree that:

I choose to designate the person named above as a proxy to my WMC patient portal, thereby allowing him/her access to my protected health information. I authorize release of any information contained in my WMC patient portal to my designated proxy. I understand that the medical information in the WMC patient portal is obtained from my electronic medical record, but is not my complete medical record, which requires a distinct release of information request to obtain.
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 receives a request for termination of Proxy access.
Participation in WMC patient portal and designating a proxy is completely voluntary. I understand that I am not required to designate a WMC patient portal proxy and I am not required to provide this authorization. I also understand 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, Williamson Medical Center may decline to provide access to my WMC patient portal to my designated proxy.
I understand that if I no longer want the proxy to have access to my WMC patient portal, I may request that Williamson Medical center revoke his/her access.

Patient Printed Name

Patient Signature

Patient Portal Proxy Access Form for Adult Patients

PROXY INFORMATION