By signing this proxy authorization request, I understand that I am requesting Frances Mahon Deaconess Hospital to disclose my protected health information (PHI) through the Patient Portal to my proxy.
I understand that my Proxy will have the same access and privileges that I have for the Patient Portal. It is understood that the proxy’s activities within my medical record in the Patient Portal may be tracked by computer and that any entries and messages may become part of my medical record.
I understand that this allows my Proxy to access my health information, which may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment of alcohol or drug abuse.
I understand this proxy request includes records that were created or existing on or before the date this form was signed, as well as records that are created after the date this form is signed.
I understand that once the above information is disclosed, it may be re-disclosed by the recipient, and the information may not be protected by federal privacy laws or regulations.
I understand this authorization will remain valid until revoked by me, or in the case of a minor, when the patient turns 18 years of age. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the Health Information Management Department. I understand that the revocation will not apply to information that has already been released to my proxy.
I understand authorizing the use of disclosure of the information identified above is voluntary. I need not sign this form to ensure health care treatment.