Patient Portal Consent Form - Northwestern Medical Center

Patient Name(Required)

Email Address(Required)

Patient Date of Birth(Required)

Confirmation

By signing, I certify that I am 18 and I understand all notifications of appointments and results will be sent to this email address.

Please read the following options carefully and only select the one that applies.

Proxy Access To Minors Medical Information Ages 0-11 +364 Days

Please check this box; if you are the parent/guardian of a child under the age of 12, and you would like them proxied to your portal.

I am a parent/guardian of a child under the age of 12, and would like them proxied to my portal.

Parent / Guardian Name

First Last

Relation to Patient:

Parent/Guardian Date of Birth

Parent/Guardian Signature

Please type your name

Proxy Access to Minors Medical Information Ages 12-17 +364 Days

Please check this box; if you are a patient between the ages 12-18 and would like to be proxied to your parent’s portal account.

I am a patient between the ages 12-18 and would like to be proxied to my parent's portal account.

(Child’s signature required for this access). Per Vermont State Law, once a child is between the ages of 12 and 17 +364 days, there are certain instances where visits between a patient and provider can be considered confidential. These visits do not have to be shared legally with the parent(s)/Guardian(s). Because of this law, we do need to have permission from the patient in writing to allow NMC staff to work with parent(s)/Guardian(s) on creating their own portal.

Parent/Guardian Name

First Last

Relationship to Patient

Certification

By signing, I certify that I understand this allows my parent/guardian online access to my personal health information. I also understand that I can revoke this access at any time by calling 802-524-1288, and that if I do not revoke this access when I turn 18, my parent/guardian will continue to have access to my health information.

Patient Signature

Please type your name

Date

Parent/Guardian Signature

Please type your name

Date

Minors Ages 12-17+364 Days Enrolling with their own Email Address

Please Check this box; if you are a patient in this age range, and you want to enroll in the portal using your own email address.

I am 12-17+364 and want to enroll in the portal using my own email address.

Patient Signature

Please type your name

Date

Minors Ages 12-17+364 Days Enrolling with A Shared Email Address

Please check this box; if you are a patient in this age range, and you would like to enroll in the portal using a shared email address

I am a patient age 12-17+364 enrolling in the portal using a shared email address.

Who You Share This Email With:

Certification

By signing, I certify that I understand all notifications of appointments and results will go to this shared email address.

Patient Signature

Please type your name

Date

Proxy Access To Other Individual

Please check this box to authorize the following individual to view your Medical Information as your proxy. Please note, the person named below must have their own portal first before they can gain access to your Medical Information.

I authorize the following individual to view my Medical Information as my proxy.

Please note, the person named below must have their own portal first before they can gain access to your Medical Information.

Proxy Name

First Last

Proxy Relationship to Patient:

Certification

By signing, I certify that I understand that the individual named above will have the same access and privileges that I have for the Patient Portal. I understand that this allows my proxy online access to my personal health information. I also understand that I can revoke this access at any time by calling 802-524-1288, and that this access does not expire until I revoke it.

Patient Signature

Please type your name

Date

If you have questions, please call Health Information Management at 802-524-1288