PATIENT GATEWAY APPLICATION

PATIENT INFORMATION

STEP 1: (ONE PATIENT PER FORM)

PATIENT ADDRESS:

(Note: for patients 13 to 17, a PCR must exist in order for the patient to have a PG account)

PATIENT CARE REPRESENTATIVE -PCR INFORMATION

IF NO– PCR ADDRESS:

AUTHORIZATION FOR PATIENT CARE REPRESENTATIVE ACCESS TO PATIENT GATEWAY APPLICATION

Note: The information available in Patient Gateway is a subset of information contained in the legal health record. Iif at any time information is needed for legal or other purposes and/or a full copy of the Patient's Medical record is needed, please contact the patient's provider directly.

I (THE PATIENT) UNDERSTAND THAT:

• I may withdraw my authorization at any time by submitting a written request to the Department or Office where I originally submitted this authorization. Authorization may be withdrawn except for the following:
  • to the extent that action has been taken in reliance on this authorization
  • if the authorization is obtained as a condition of obtaining insurance coverage, other laws provide the insurer with the right to contest a claim under the policy
• I may refuse to sign this authorization. If I refuse to sign this authorization, my treatment, payment, health plan enrollment, or eligibility for benefits will not be affected
• Information released on this authorization, if redisclosed by the recipient, is no longer protected by Partners HealthCare
• I understand that this authorization will remain in effect until one of the following occurs:
  • A patient 12 years or younger reaches the age of 13 years; a new authorization form is required
  • A patient reaches the age of 18 years; a new authorization form is required
  • Closure of account is requested in writing by the patient, their Legal Guardian, or Patient Care Representative
  • In the event of death of the patient or Patient Care Representative
• Partners, the patient, their Legal Guardian, and/or the patient's Patient Care Representative may elect to suspend or terminate authorization to Patient Gateway access at any time, for any reason

PATIENT AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION TO PATIENT GATEWAY PATIENT CARE REPRESENTATIVE

I have carefully read and understand the above, and have had any questions explained to my satisfaction.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

I have carefully read and understand the above, have had any questions explained to my satisfaction, and do herein expressly and voluntarily authorize disclosure of the above information about, or medical records of, my condition to the person or agency listed above for the purposes of enrollment and utilization of the Patient Gateway application.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

When patient is a minor, or is not competent to give consent, the signature of a parent, guardian, or other legal representative is required.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.