Patient Portal Proxy Access Form (0-13 Years Old)

Patient Portal Proxy Access Form (0-13 years old)
Patient Information
Patient Name: Last, First, MI*
Patient Date of Birth*

MonthDayYear
Patient Last 4 numbers of SSN*
*if newborn you may enter NA
Parent/Legal Representative Information and Agreement
Please note you must provide your email address in order to be granted proxy access. For all types of proxy access, the patient’s chart will be accessed through the proxy’s patient portal account
Name (Last, First, MI) of Parent/Legal Representative *
Date of Birth of Parent/Legal Representative*

MonthDayYear
Last 4 numbers of SSN of Parent/Legal Representative *
Email of Parent/Legal Representative *

Confirmation Email
Address of Parent/Legal Representative *

Street Address

Street Address Line 2

CityState

Zip Code
Proxy Relationship to Child:*

MotherFatherOther Legal Representative
Has the parent/proxy ever been a patient at Williamson Health?*

YesNoUnsure
Does the parent/proxy have an active patient portal account?*

YesNoUnsure
*For non-biological representatives, please provide legal documentation to hospital or fax to 615-435-5775. This includes: Custody,Adoption Decree, Power of Attorney, Conservatorship, Guardianship, Department of Children’s Services Letter for Foster Parents, etc.You may also submit documentation via secure email to: PortalHelpDesk@willliamsonhealth.org. Please note that if the email is not sentsecurely (i.e., unencrypted email) it may be intercepted and seen by others during transmission. By choosing to send information byunencrypted email, you accept these risks
Parent: Is there a court order in effect limiting your access to the minor’s medical records and information?*

YesNo
Individuals requesting access must have parental rights or legal guardianship rights.

I am the parent or legal representative of the child/children named above and I request access to the child’s information online through theWilliamson Health patient portal. I understand the requirements and procedures for accessing the child’s information online through thepatient portal. All the information I have provided is correct, and I have rights to access the child’s information online through patient portal.I understand that access will be revoked when the child turns 14 and a new request for patients aged 14-17 must be completed.
Parent/Proxy Printed Name: *
Parent/Proxy Signature:*

Clear
Date:

MonthDayYear
For assistance, you may call the number below or email our portal helpdesk by clicking on the link below or scanning the QR code.

Phone: 615-435-5757

Email: PortalHelpDesk@WilliamsonHealth.org

Patient Portal site: https://williamsonhealth.org/patient-portal/
Should be Empty:

Patient Portal Proxy Access Form (0-13 years old)

Patient Information

Parent/Legal Representative Information and Agreement