By signing this form, I authorize to communicate with me via the secure web Patient Portal regarding my medical care. I will be notified via my personal e-mail when information can be found in my Patient Portal. No personal health information is transmitted via or into my personal e-mail. It is understood that the following types of protected health information may be used, disclosed, and retained by health care providers of [clinic name] as a result of the communications: my personal health information, laboratory test results, pathology reports, other diagnostic test results. I am responsible for protecting my username and password and will notify [clinic name] if this information is compromised. Even though I can access the Portal at any time, there is not a 24 hour presence at [clinic name] and messages may take up to 2 business days to be answered. I agree to provide factual and correct information, and realize that the Portal is not intended to provide internet based diagnostic services. I understand that a new authorization must be signed each year.

I MAY USE THE PORTAL:

1. Use the message function to communicate with our staff
2. Schedule, confirm, cancel or reschedule an appointment
3. Communicate about billing questions
4. Request a referral or medication refill
5. View health summary information and send staff requests to update information
6. View demographic / insurance information and send staff requests to update information
7. View, download, and transmit an electronic copy of the health summary using the continuity of care document (CCD) format.

HOW THE PORTAL MAY BE USED BY THE OFFICE STAFF:

1. Communicate through messages received via the patient portal
2. Send results of lab or other diagnostic tests via the portal and include messages related to the results
3. Receive requests for medication refills and billing questions
4. Receive appointment requests
5. Send appointment confirmations to portal patients

Patients and/or personal representatives who want to communicate with their health care providers by Patient Portal should consider all of the following issues before signing this Authorization

1. Portal communication is a convenience and not appropriate for emergencies or time sensitive issues.
2. Portal messages received at can be forwarded, printed and/or read, stored by staff members.
3. We advise caution when communicating highly sensitive or personal information via Portal messages.
4. Clinically relevant messages and responses will be documented in the medical record.

I understand that I have the right to revoke this Authorization at any time. If I want to revoke this Authorization, I must do so in writing and address it to clinic either by Portal communication or regular mail. I understand that if I revoke this authorization, it will not apply to any information already released as a result of this authorization. Clinic also reserves the right to change policies, suspend accounts or terminate the Portal for abuse or any other reason. I understand that I may refuse to sign this Authorization. I acknowledge that using the Portal is entirely voluntary and will not impact the quality of care I receive from clinic should I decide against using the Portal.

By agreeing, I acknowledge that I would like a Patient Portal account and agree to the terms and conditions set forth above.