PATIENTS 13 YEARS THROUGH 17 YEARS: Upon age 13, an authorization form signed by the adolescent patient is necessary to provide a parent/legal guardian Authorized Representative access to your portal account. If you consent to assign a parent/legal guardian as your Authorized Representative, CNY Family Care will automatically terminate the Authorized Representative permissions the day before your 18th birthday.

Please understand, on the portal all a patient's medical information, visit notes, and test results may be available to view. You also have the capability to update and edit the patient's medical, social, and family history. Changes that you make will become part of the patient's permanent medical record.

You have chosen to have an Authorized Representative access your patient portal account at CNY Family Care. An Authorized Representative has the same level of access as a patient, and will provide them the ability to access different parts of your medical record on your patient portal. As a user of an Authorized Representative portal account, you both must agree to the terms and conditions below.

Please note that failure to follow these terms and conditions can result in the termination of the Authorized Representative portal account.

PATIENT - I understand that:

• Use of the Patient Portal Authorized Representative is voluntary, and I am not required to grant another person (proxy) access to my Patient Portal Account in this manner.
• By signing this document, I acknowledge that I have read and understood the information within this document. I am granting this proxy to have access to my personal health information in the form of an Authorized Representative Portal Account.
• I may terminate this Authorized Representative's access to my patient portal account at any time by contacting CNY Family Care unless there is a court order in place granting this AR full access to my medical records.
• I understand that there can only be two Authorized Representatives for my patient portal.
• I was allowed to ask questions about the patient portal, and CNYFC has answered all my questions to my satisfaction.
• I understand that this authorization will cover disclosure of information on the portal relating to ALCOHOL or DRUG TREATMENT, PREGNANCY, SEXUALLY TRANSMITTED DISEASES, PSYCHIATRIC CARE, and CONFIDENTIAL HIV RELATED INFORMATION.
• I understand that Federal and New York State Laws establish who CNY Family Care may share my protected health information with. Under New York State Law, as a minor age 13 17, my medical information is accessible to my parent/ guardian. My consent is only required to share my medical information with my parent/ guardian for medical care that relates to  reproductive health care, including family planning (i.e., birth control and other contraception), emergency contraception, abortion, pregnancy/prenatal care, care during labor and delivery, care for sexually transmited infections; certain mental health services; certain alcohol and drug abuse services; and sexual assault treatment. The decision to consent for myself to have access to my patient portal, or to consent for my parent/guardian to have access to my patient portal, does not change or restrict whom CNY Family Care can share my protected health information with.

AUTHORIZED REPRESENTATIVE - I understand that:

• Authorized Representative access is used to access the above patient's personal health information. I may not share my login and password information with another person.
• I may use this Authorized Representative access to send messages about this patient ONLY.
• It is my responsibility to select a personal login name and password, to maintain this data securely, and to change this password or contact CNY Family Care immediately if compromised in any way.
• CNY Family Care, LLP has the right to revoke access to the Patient Portal by a patient or their Authorized Representative at any time for any reason.
• It is my responsibility to ensure that my e-mail address is current at all times. I understand that if my e-mail is not up to date, I will not receive notification of messages sent to me regarding this patient.
• I'm aware that I should handle urgent issues by calling the office directly or calling 911 should the emergency be life-threatening.
• I understand the given risks associated with online communications between my child's physician and myself.
• I was allowed to ask questions about the patient portal, and CNYFC has answered all my questions to my satisfaction.

By signing below, I acknowledge that I have read and understood this Patient Portal Authorized Representative Authorization Agreement Form, and I agree to its terms. I choose to designate the person named above as my Authorized Representative, thereby allowing them access to my medical record via my CNY Family Care Patient Portal Account.