Get Patient Portal Access / Proxy Form - Bothwell Regional Health Center

This guide provides clear and supportive instructions on how to accurately complete the Patient Portal Access / Proxy Form for Bothwell Regional Health Center. Filling out this form will enable authorized individuals to access your patient information conveniently online.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it for filling out.
2. Begin by entering the patient name in the designated field. Ensure the name is printed clearly and accurately.
3. Enter the patient's date of birth in the specified section. This information is important for verifying identity.
4. Provide the patient's email address. Make sure it is an active email as this may be used for communication regarding the patient portal.
5. Fill in the patient's phone number to enable contact if needed. Include the area code for accuracy.
6. In the proxy email address field, enter the email address of the individual you wish to authorize as your proxy for the patient portal.
7. Print the name of the proxy in the designated area to clearly indicate who will be accessing the account on behalf of the patient.
8. Provide the proxy's date of birth to assist in identity verification.
9. Enter the proxy's phone number, including the area code.
10. Complete the proxy's address in the space provided. This is essential for contact and verification purposes.
11. Read the authorization statement carefully and ensure you understand it before signing. This confirms your consent for the proxy to access your health information.
12. Sign the authorization as the patient. If necessary, include the signature of the parent or legal guardian on the specified line.
13. If applicable, the proxy should also provide their signature to finalize the authorization.
14. Review the completed form for any errors or omissions and make corrections as needed before proceeding.
15. Once the form is accurately filled out, save changes, download, or print a copy for your records.

Complete your Patient Portal Access / Proxy Form online to ensure seamless access to your health information.