PATIENTS 13 YEARS THROUGH 17 YEARS: You have requested to have online access to the portal at CNY Family Care without an Authorized Representative having access. For patient's age 13-17 it is our policy that you must sign this consent form, prior to access being granted, to ensure you are aware of your responsibilities when accessing and using the patient portal.

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

You have the right to add an Authorized Representative to your portal account at anytime. Upon age 13, an authorization form signed by the adolescent patient is necessary to provide your 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 permission to the portal the day before your 18th birthday.

Please note that failure to follow the terms and conditions below can result in the termination of your portal account.

PATIENT - I understand that:

• 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.
• For any portal technical issues, I understand CNY Family Care can only speak to me, and any new login or portal reset codes can only be shared directly with me and not my parent/ guardian.
• I may not share my login and password information with another person.
• 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.
• I understand that this authorization may 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 may use this portal to send messages about myself ONLY.
• 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 doctor and myself.
• I was allowed to ask questions about the patient portal, and CNYFC has answered all my
  questions to my satisfaction.
• 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. If understand that if I want to add an Authorized Representative at a later date I may do so my completing the necessary consent form.
• CNY Family Care, LLP has the right to revoke my access to the Patient Portal at any time for any reason.
• 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.
• By signing this document, I acknowledge that I have read and understood the information within this document.