Patient Portal Proxy Access Request & Authorization

Patient Portal Proxy Access Request & Authorization
Patient Name*

First NameMiddle InitialLast Name
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Today

MonthDayYear
Date
Age
Portal Connections are not available for any patient aged 12-17 due to legal responsibilities to Illinois Law.

https://www.springfieldclinic.com/athenahealth-portal-help#shared-access
Last 4 SSN#*
This form is an Authorization that will permit the person named as your proxy (on following screen) to have access to the information about you in your patient portal. Please read it carefully. All of your medical information that is available in your patient portal will be available to your proxy if you sign this Authorization. Patient portals include information related to mental health treatment, sexually transmitted diseases, HIV/AIDs, genetic testing, and incidental records related to alcohol and substance abuse. If there is information that you do not want your proxy to see, then you should not sign this Authorization.

I understand this permits the proxy I have authorized to have access to the above information.
Patient Initials*
Health information to be accessed: All information contained in my patient portal medical record.

Purpose of portal access: To allow my patient portal proxy to view my medical information.

I authorize the release of my patient portal medical information to my proxy through proxy access to my patient portal account. This Authorization does not authorize the release of my medical information by other methods or other formats. I understand that once information has been disclosed, it may potentially be re-disclosed by my proxy and the disclosed information may not be protected by state or federal privacy laws. I understand that authorizing Springfield Clinic and my physician to disclose my medical information to my proxy via the patient portal is voluntary. I understand that Springfield Clinic will not condition healthcare treatment or payment for treatment upon my signing this Authorization. Springfield Clinic and my physician are not receiving any remuneration from any third parties because of this Authorization. This Authorization will remain effective until revoked in writing or the patient's portal account is terminated. You may revoke this Authorization at any time by submitting a written request to revoke proxy access by mailing to Springfield Clinic - 3201 Robbins Road - Springfield, IL 62704 or emailing portalsupport@springfieldclinic.com. I understand that a revocation is not effective for uses and disclosures of my medical information that have already been made or other actions that have been taken in reliance on this Authorization or as required by law. I understand that I am entitled to a copy of this Authorization and that I may review a copy of Springfield Clinic’s Notice of Privacy Practices at any time by visiting https://www.springfieldclinic.com/patient-tools/privacy or contacting my physician’s office. If you have any issues related to proxy access, please reach out to our portal support team at portalsupport@springfieldclinic.com or calling us at 217.572.1731. We are happy to help with any of your portal-related questions. I acknowledge and agree that I will comply with all requirements listed in the Springfield Clinic Patient Portal Terms and Conditions of Use Agreement and this document.
Patient signature for patients 18 and over or Parent OR Parent/Legal Guardian signature for children under 12*

Clear
Relationship to Patient
Date

MonthDayYear
Date

Proxy Information
Proxy Name*

First NameMiddle NameLast Name
Proxy Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Type of Access/Relationship:*

Adult patient: Access to another adult's patient portal information (includes emancipated minors who have provided proof of emancipation)Minor patient: Access to a minor child's patient portal information (includes patients 0-11 years old)
What is your relationship to the patient?*

Adult-capable Adult Patient (patient must sign form to provide authorization for release of patient portal information. Authorization for Proxy access is valid until revoked in writing by the patient)Legal Guardian of Adult-dependent Patient (appropriate paperwork required)Health Care Agent of Adult-dependent Patient (appropriate paperwork required)
What is your relationship to the minor?*

ParentLegal Guardian
llinois law allows a minor (age 12-17) to confidentially seek care for services such as birth control, sexually transmitted disease, HIV testing, substance abuse and mental health services. These laws are in place to protect adolescents who wish to keep some health care decisions private. However, technical limitations do not allow partial access to Portal information. Thus, Springfield Clinic must turn off all access to the Portal in order to satisfy its legal obligation to protect the privacy rights of these minors.

Please upload a photo of your Driver's License*

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Please upload appropriate legal guardian and health care agent documentation for adult patient access*

You must provide a copy of the guardianship letters of office or executed healthcare power of attorney verifying your authority to have access to the patient's medical information. You must notify Springfield Clinic of any changes in that authority
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Patient Portal Proxy Access Request & Authorization

Proxy Information