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Patient Access Form

Consent for Patient Portal Access
Northeastern Vermont Regional Hospital

Patient Name  
Patient Date of Birth  
          I am requesting access to NVRH MyPortal patient portal for access to my own medical information.
Patient Email:  
Patient Phone Number  

          I authorize the following individual to participate in Northeastern Vermont Regional Hospital's Patient Portal as my proxy.
          I want to revoke the the following individual from accessing my NVRH MyPortal patient portal account.
Proxy/Care Partner Name:Relation to Patient:
Proxy/Care Partner AddressPhone Number
Proxy/Care Partner Email Address
(this must be different than the patient's email)

I understand that my proxy or care partner will have the same access and privileges that I have for the Patient Portal. I understand that this allows my proxy/care partner online access to my personal health information. My proxy/care partner will be able to view the portions of my record that I am able to view. I also understand that additional information may be made available to my proxy/care partner through the patient portal as Northeastern Vermont Regional Hospital continues to implement this product. This access will include the ability to securely message my provider offices.

By signing this authorization, I am requesting Northeastern Vermont Regional Hospital to give access to my proxy/care partner to utilize the patient portal. I understand that Northeastern Vermont Regional Hospital will require my proxy/care partner to electronically acknowledge and agree to Northeastern Vermont Regional Hospital's policies and procedures for use of the patient portal.

This authorization is valid until revoked by me. I understand that a written request is necessary to revoke or cancel this authorization. However, I understand that my revocation will not be effective as to uses and/or disclosures already made in reliance upon this authorization. I realize that the information used and/or disclosed pursuant to this authorization may be subject to re-disclosure and no longer protected by federall privacy laws.

Patient Acknowledgement
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 ***

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