Message and requests sent to your doctor's office are NOT monitored 24/7.
If you are experiencing a medical emergency, you should call 911 immediately.
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.
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
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.
Please enter your registered email address to send your new password.