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Permission to Grant Portal Access to Parent/Guardian

Are you 18 or older?

Fill out the following form to grant access to your medical records on the portal for your parent/guardian. A confirmation email will be sent to the patient’s email below and after answering the email, access will be granted to the parent/guardian.

Note that your parent/guardian can not have access without your written permission or electronic signature below.

By completing this form, you an 18 year old and over patient is granting portal viewing privileges to the parent/guardian listed on form. Please note that a confirmation email will be sent to the patient's email address provided. It is a considered a privacy violation and a criminal offense to falsify access when it has not been granted by the patient. This form is to be filled in ONLY by the patient granting access. Thank you.
Parent's First Name
Parent's Last Name
Parent's Email
Name of Parent or Guardian Patient Granting Access
Email Address Used by Parent to Access Portal