Delegate Form

Delegate Form- Access to a patient portal account
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
Date
I give access to the individual listed below (Authorizaed Person/Delegate) to my patient portal account:
Name of Authorized Person (Delegate)

First NameLast Name
Date of Birth of Authorized Person (Delegate)

MonthDayYear
Date
Gender of Authorized Person (Delegate)
Phone of Authorized Person (Delegate)

Area CodePhone Number
Email for Authorized Person (Delegate)
example@example.com
Relationship to Patient:
Please fill out the following information about the delegate you are sending an invite to
Delegate access is granted for 1 year from form completion and must be renewed by patient request by contacting the practice.
Patient Signature
Date

MonthDayYear
Date
Should be Empty:

Delegate Form- Access to a patient portal account