Patient Portal Access Request Form

I'm Requesting Patient Portal Access For:

If 'Another Person', you're requesting 'Proxy' access

Myself Another person

First name

First name of the patient

Last name

Last name of the patient

Date of Birth

Relationship to the Patient

How Can We Reach You?

We need to call you to verify your identity in order to grant Patient Portal access.

Your First Name

Your Last Name

Telephone

Telephone Type

Mobile/Cell (Peferred)

Landline

VOIP (i.e. Google Voice, Vonage, etc.)

Your Email Address

The email address that you provide will be linked to your patient portal access. It's best to provide a personal (i.e., non-work/employer) email address. It must also be unique - for example, spouses must use a unique email address for patient portal access. They cannot be shared. If this is a Proxy request, then you can not use the same email address used by the patient.

Email address

Confirm Email address

Please Read Before Submitting!

Submission of this form constitutes a preliminary request for Proxy Access. Access will not be granted based on the information submitted in this short form.

Our staff will review the request. This can include reaching out to the patient. If we determine that this is a legitimate/legal request for Proxy Access, we will then send a more comprehensive secure form to the email address provided. You will need to fill out this 2nd form in detail, and legally-binding eSignatures will be required before submitting.

Your information will be encrypted.