Proxy Portal Consent Form

The eClinicalWorks (eCW) Patient Portal provides online access to patient information, which may include problem list, allergies, medications, lab and radiology results, and other clinical documents. By using eClinicalWorks Patient Portal this information can be accessed at your convenience.

You are accessing the eCW Patient Portal of another patient in which you have been granted Proxy access. Please note the following age limitations for access to a minor’s eCW Patient Portal. These range limitations do not affect any legal right you have to access your child’s records by other means.

If your child is age 0-11, parent/legal guardian will be granted full access to the child’s eCW Patient Portal record.
If your child is age 12-17, parent/legal guardian will be granted partial access (immunizations only) to the child’s eCW Patient Portal record
Once your child reaches 18 years of age, parent/legal guardian will not be granted any access to the eCW Patient Portal patient record unless the patient provides consents to access.

Full access to another adult’s information will be granted upon request from the patient. If the individual has diminished capacity, full access will be granted to the health care agent, or legally authorized representative.

Please read carefully. Your acceptance indicates that you have read, understand, and agree to these Terms and Conditions of Use.

I understand that I have been granted Proxy Access to a minor or other individual’s eCW Patient Portal. I understand that Proxy Patient Portal access I have been granted will be either complete or limited/restricted dependent on the patients age, if they are a minor. I understand that granting proxy access to a third party is completely voluntary.
I will not share my confidential login credentials with anyone else for use to access the patient’s eCW Patient Portal. I understand the importance of keeping my login credentials confidential for the safety and privacy of the patient.
eClinicalWorks and Valencia Pediatric Associates are not to be held liable for any unauthorized access to the patients’ health information that may result from you not protecting your access credentials.
I understand that the Patient Portal is not to be used in emergency situations. If there is a medical emergency or an urgent medical question, I will contact Valencia Pediatric Associates of directly or call 911.
I understand that my any activities within the eCW Patient Portal completed by the Proxy, myself, may be tracked by computer audit and that any entries and messages may become part of the medical record.
I understand that as a Proxy, I will receive an email notification any time new information is available in the patients Patient Portal. The notification itself does not contain any medical information, however, I understand that if I do not want to continue receiving these notifications, I can select the “Unsubscribe” option at the bottom of any Patient Portal e-mail to stop further notifications.
I understand that access to the eClinicalWorks Patient Portal is provided as a convenience to patients and that Valencia Pediatric Associates has the right to deactivate my Proxy Portal access at any time for any reason or for no reason.
I understand that my use of eCW Patient Portal is voluntary and that I am not required to use the Patient Portal for myself or as a Proxy, on behalf of another patient.
As the Proxy, I have read and understood the requirements for accessing the Patient’s eCW Patient Portal account information and agree to abide by the according terms and conditions.

By selecting “Accept” below, I confirm all of the representations and warranties above, and as the Proxy user, I hereby accept the duties and responsibilities of being granted access to the Patient’s medical information.

Patient Portal/Healow Access - Minor Patient Proxy Authorization

Minor Proxy

A proxy authorization means that you give another person full access to your Patient Portal/Healow Medical Records through an online patient portal account. They can email your doctor’s office, refill your prescriptions, and schedule your appointments through the Patient Portal/Healow App. It is as if they were you. This might be a parent or guardian who helps you take care of your health. You must complete the whole form.

Please print clearly

Patient Information:

Patient Last Name:

Patient First Name:

Patient Middle Initial

Date of Birth:

Age:

Street Address:

City:

State:

Zip Code:

Cell Phone Number:

Email address

Proxy Information - You must complete a separate form for each proxy request.

Proxy's Last Name:

Proxy's First Name:

Proxy's Middle Initial

Date of Birth:

SSN Last Four Digits:

Cell Phone:

Street Address:

City:

State:

Zip Code:

Email address

Legal Relationship to the Patient:

Valencia Pediatric Associates can release health information for the patient to the proxy listed above through an online Patient Portal/Healow account. The proxy listed above can email the patient’s doctor’s office, refill the patient’s prescriptions, schedule appointments, and view medical records including documents from Non-Essential Health Providers for the patient through Patient Portal/Healow App.

It is understood that:

For minors 0 to 11 years old, the proxy will have full access to the minor’s Patient Portal-Healow Medical Records including documents from Non- Essential Health providers until their 12th birthday.
For minors 12 to17 years old, if the minor does not sign this form, the proxy will only see a part of their Patient Portal Medical Records.
For minors 12 to 17 years old who sign this form, the proxy will have full access to their Patient Portal/Healow Medical Records including documents from Non-Essential Health providers for one year. The proxy will need to fill out a new authorization form each two years to renew access.
Minors 12 to 17 years old can change their mind about proxy access to Patient Portal/Healow at any time by letting Valencia Pediatric Associates know in writing. When Valencia Pediatric Associates gets the note, the change will be made no later than the next business day. The change will not apply to information that has already been released before the effective date.
Minor Patient Proxy Authorization ends when a patient turns 18 years old.
Valencia Pediatric Associates cannot be responsible for the privacy of information given to the proxy. Valencia Pediatric Associates cannot prevent the proxy from giving information to another person. At that time, the information is no longer protected by federal and state privacy rules.
If I do not sign this form, Valencia Pediatric Associates will still provide treatment to the patient. This form will not affect payment, enrollment, and eligibility for benefits.
You must complete, sign, and date this form for it to be valid. A photocopy, fax or electronically scanned and transmitted image is the same as the original.
You can have a signed copy of this form, at your request.
For the proxy to gain access to your Patient Portal-Healow account, the proxy must activate the account with through their email. The proxy must confirm that they have read and agree to the Valencia Pediatric Associates Terms and Conditions. These Terms and Conditions apply to each use.
I designate my Patient Portal-Healow account as my preferred method of communication to receive reminders about preventative and follow-up care (excludes scheduled appointment reminders).
I understand additional medical records may be requested through Valencia Pediatric Associates Release of Information.

Signature of Minor between the ages of 12-17 granting the Proxy full access to Patient Portal/Healow

Today’s Date

Signature of Proxy

Today’s Date

Mail, email or fax completed forms to the following address:

Valencia Pediatric Associates
27867 Smyth Drive Suite 100
Valencia, CA 91355
Phone: 661-294-2229 (option 2) | Fax: 661-294-8399
E-mail: info@valpeds.com

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