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 with the ability to access different parts of your medical record on our patient portal. As a user of an Authorized Representative portal account, you both must agree to the following terms and conditions.

Please understand that the Authorized Representative will have access to visit notes, and test results on the portal. The Authorized Representative can also update and edit the patient's medical, social, and family history. Changes made by the Authorized Representative will become part of the patient's permanent medical record.

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 may cover disclosure of information on my portal relating to ALCOHOL or DRUG TREATMENT, PREGNANCY, SEXUALLY TRANSMITTED DISEASES, PSYCHIATRIC CARE, and CONFIDENTIAL HIV RELATED INFORMATION.

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 to 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 the 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.