Medical Records Patient Portal Consent Form

Medical Records Patient Portal Consent Form
Reason for Medical Records Request:*

For personal use – I am requesting a copy of my records for my own files.Send my records to my doctor or facility to support ongoing care.Both – I am requesting a copy for my personal use and to provide to my referring physician.Legal request – If you are submitting a subpoena or request on behalf of a lawyer, please go to ChartSwap.com
Since this request is solely to share your records with your referring physician for ongoing care, we will provide both the report and the images and can fax the necessary documents directly to your doctor’s office within 24-48 business hours.
Referring Physician or Facility Name
Fax number
Please enter a valid phone number.
Was your recent exam at?*

WIC- Women's CenterIPOC - Imaging Partners
Please specify the approximate date of service year(s) of the records you need,
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Mobile number? (This number will be used to provide the link to access the Patient Portal. Please make sure it is correct.)*
Please enter a valid phone number.
How would you like to help us verify your identity with our records?

Take a photo of your government-issued ID (e.g., Driver’s License, Passport, State ID)Provide the ID number used during your visit (e.g., Driver’s License or other legal ID)
Take Photo
Driver’s License Number or Other Legal ID (e.g., Passport, State ID)
Enter the number exactly as it appears on the ID.
Email*

Confirmation Emailexample@example.com
Check this box if the email address belongs to the patientThis email is not the patient’s—please provide the name of the person it belongs to.
1. Purpose

The purpose of the Patient Portal Consent Form is to get consent from patients who will use the Patient Portal with given credentials in order to access, view and monitor their medical conditions.

It is intended to present possible risks, benefits and conditions of the Patient Portal to patients with this Patient Portal Consent Form.

2. Patient Portal

Patient Portal is a web portal which allows patients to view and reach their medical records which are lab results, medical history and medications. The patient can access the secure Patient Portal via the internet.

3. Confidentiality

Medical and personal information of the patient are protected by the state and federal laws. The patient can access the Patient Portal via his or her credentials and it is the patient's responsibility to protect the credentials from unauthorized people, services or organizations.

4. Risks

The medical information, personal information and communication channels in the Patient Portal are protected securely. However, the patient needs to be careful while using the portal. The patient should be sure that the message is sent to the correct email address.
Who is completing this form?

I am the patientI am the patient’s legal representative (e.g., parent, guardian, power of attorney)
If applicable, please upload supporting documents such as a Medical Records Release form.

Cancelof
Representative Name

First NameLast Name
Relationship to Patient

ParentGuardianRepresentativeSurrogateLegal Authority (if applicable)
I have been informed about the potential risks, benefits and confidentiality of the Patient Portal. I acknowledge that the information I have given is accurate and complete. By signing below, I, as a patient or a representative, accept all the terms & conditions and I accept that I am the responsible party for protecting my credentials that are used to access the Patient Portal. I have fully understood the policies and wish to participate in the Patient Portal.
Date

MonthDayYear
Date
Patient/Representative Signature*

Clear
IEmail
example@example.com
WEmail
example@example.com
Should be Empty: