Patient Access Form

Patient First and Last Name (Required)

Patient DOB (Required)

Gender Gender Male Female Other

PATIENT ACCESS PATIENT ACCESS Please check this box; if you are the patient and want access to MyPortal to view your own medical information.

Email (Required)

Phone Number (Required)

Patient Signature and Date (Required)

By signing this consent form, I acknowledge that this authorization is valid until revoked by me in writing. 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 the information used and/or disclosed pursuant to this authorization may be subject to re-disclosure and no longer protected by federal laws.

PROXY ACCESS PROXY ACCESS Please check this box to authorize the following individual to view your records as your proxy – OR– if you are the parent of a child under the age of 12.

Proxy First and Last Name (Required)

Proxy Relation to Patient (Required)

Proxy Email (Required) must be different than patient's email

Patient Signature and Date (Required)

I understand that my proxy care partner will have the same access and privileges that I have for the Patient Portal. I understand that this allows my proxy online access to my personal health information. I also understand that additional information may be available to my proxy through the patient portal as Northeastern Vermont Regional Hospital continues to implement this product. This will include the ability to securely message my providers offices.

ACCESS TO MINORS MEDICAL INFORMATION ACCESS TO MINORS MEDICAL INFORMATION Please check this box if you would like access to your child's medical information of MyPortal. (Ages 12-17)

Relation to Patient (Required) Relation to Patient (Required) Birth Parent Adoptive Parent Legal Guardian

Parent Guardian Email (Required)

Parent/Guardian Signature and Date (Required)

By signing I certify that I have read the above terms and that I am the legal parent or guardian of the above minor.

Minor Patient Signature (Required) ages 12 – 17

By signing I certify that I have read the above terms and that I am the minor patient.

I understand that this allows my proxy online access to my personal health information. I also understand that additional information may be available to my parent/guardian through the patient portal as Northeastern Vermont Regional Hospital continues to implement this prodcut. The access will include the ability to securely message my provider offices.

MINOR ACCESS TO MEDICAL INFORMATION MINOR ACCESS TO MEDICAL INFORMATION Please check here if you would like your child to have access to their medical information on MyPortal

Minor Email (Required) must be different from parent/guardian email