Patient Portal Release Form

8160 Seaton Place ▪ Montgomery, Alabama 36116 ▪ (334) 272-1799 ▪ Fax: (334) 272-4876 136 East Main Street ▪ Prattville, Alabama 36067

Please correct the errors described below.


Our Patient Portal offers you a convenient, anytime access to patient health information and puts YOU at the center of your healthcare. With the ability to view accurate health records, lab results, and communicate with your doctor, you are helping us to expand and improve your health care experience!

Always dial 911 for emergency situations. DO NOT leave a message on the Patient Portal as it could take 24-48 hours for a response.

I further acknowledge:

I have been given my portal login information.

I understand it is my responsibility to maintain the confidentiality of the information contained in the documents.

I understand the patient portal should NOT be used for emergency situations.

I understand messages will not be addressed if received from any individual who is not currently authorized on my Registration Form to obtain such information according to HIPAA patient health information (PHI) privacy rules.

Your information will be encrypted.