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Parental Access Form


Parental Access to the Online Medical Record of a Patient 12 to 17 years Old

Child's Name  
Child's Date of Birth  
          I hereby request access to View my child's medical information through the MyPortal patient portal.
Parent Email:  
Phone Number  

As a parent, you can request your child to have access to his/her online medical record.
          I am hereby request that my child have access to their online medical record.
Child's Email:  

Please enter Birth Parent/Legal Guardian information below:
Parent Name:Date of Birth:
Relationship to patient    Birth Parent     Adoptive Parent     Legal Guardian     Other
If other, please specify: 
Note: Access to the child's online record is only available to birth/adoptive parents or individuals with legal guardianship.
Do you (parent/legal guardian) already have a MyPortal account?    Yes     No     Don't know

I have read and understand the requirements and procedures for accessing my child's medical record information online as provided on the page one of this document titled, Parental Access to the Online Medical Record of a Patient 12 to 17 years old. I certify that I am the birth parent or legal guardian of the child listed above and that all information is true to the best of my knowledge.
 
Parent Electronic SignatureDate
                         I understand that checking this box constitutes a legal signature.
Patient Electronic SignatureDate
                         I understand that checking this box constitutes a legal signature.
 
*** TIME SENSITIVE - Once you receive the initial email from no_reply@nvrh.org, you have 72 hours to log in and create your personal ID and Password ***



Instructions and Education for the Patient

Access to MyPortal online medical record allows a birth parent or legal guardian and/or the patient to access the patient's medical information via the internet.

For children who are 12-17 years old, a birth parent or legal guardian can access the online medical record with the child's consent. With the consent of a parent or legal guardian, children 12-17 years old can access their own online record.

The MyPortal Online account contains medical information including but not limited to: lab results, provider reports, medication list, allergy list, past and future appointments, condition list, and electronic messages to the provider office.

As the patient, I understand that:
  • I have a MyPortal Online account or an account will be established for me
  • I must log in to MyPortal with my own username and password
  • To protect the privacy of my health information, I will not share my username and password with anyone
  • I agree to abide by the terms and conditions on the MyPortal Online website
  • When I turn 18, parent/legal guardian access will be terminated
  • I can terminate the parent/legal guardian access by contacting NVRH Medical Records at 802-748-7362 or by emailing portal@nvrh.org.
  • I recognize that MyPortal Online is not to be used in an emergency
  • If I want my own MyPortal Online account, I must have my own email
If a patient becomes emancipated from their parent or legal guardian, disagrees with the parent or legal guardian access, or would like to find out more information about the MyPortal Online access, the patient can email portal@nvrh.org, call their provideris office, or call NVRH Medical Records at 802-748-7362.

Northeastern Vermont Regional Hospital
PO Box 905 1315 Hospital Drive
St. Johnsbury, Vermont 05819
802-748-8141
TTY/TTD, Dial 711
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