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.