New Portal and Permission to share PHI

Protected Health Information (PHI) & New Portal Account Registration
After you reach the age of majority at 18, the privacy of your personal health information is protected under the Health Insurance Portability and Accountability Act, known as HIPAA.

Health care providers are not legally permitted to disclose your medical record or even discuss your health status or treatment recommendations with anyone.

Whether or not you decide to grant your parents (or another trusted adult) access to your records and permission to speak with your health care providers, you must complete this form so that we can create a new portal account or you.

Please let us know If you have questions.
Your Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Cell Phone Number*
Please enter a valid phone number.
Do you wish to allow someone to have access to your protected health information (PHI)? This also applies to appointment reminders.*

YesNo, not at this time
Level of Access*

Full Access - Unrestricted access to all medical recordsLimited Access - Appointments, billing, insurance, or specific records
Name of individual(s)*
Relationship to you:*

MomDadStep MomStep DadBoth parentsFriendOther family memberOther
By signing this form, I give permission to the person(s) listed above to have access to my Protected Health Information (PHI) information as specified in the indicated Level of Access section. This permission will be considered ongoing until I state, in writing, otherwise.
By signing this form, I do not wish to give permission to anyone to have access to my Protected Health Information (PHI) except as permitted by state or federal law.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Protected Health Information (PHI) & New Portal Account Registration