18-21 year old Patient Portal Sign Up

Patient Portal access for 18-21 year old patients

Comments

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Patient's Name(Required)

First Last

Date of Birth(Required)

Primary Phone Number(Required)

Email(Required)

Optional Proxy Portal Access Permission

PERMISSON TO ACCESS MY PROTECTED HEALTH INFORMATION ON PAR’S PATIENT PORTAL: I agree to give the following permission to access my Patient Portal account with restricted access.

Proxy's First & Last Name

Proxy's Date of Birth

Proxy's Primary Phone Number

Proxy's Email

Proxy's Relation

Proxy's First & Last Name

Proxy's Date of Birth

Proxy's Primary Phone Number

Proxy's Email

Proxy's Relation

Terms and Conditions(Required)

The Pediatric Associates of Richmond (PAR) Patient Portal provides online access to patient information,
which may include vaccine records, appointment history, medication refills, lab results, billing
information and other clinical documents. By using the PAR Patient Portal this information can be
accessed at your convenience.
Please note the following age limitations for access to a minor’s PAR Patient Portal. These range
limitations do not affect any legal right you have to access your child’s records by other means.
– Once you reach 18 years of age, parent/legal guardian will not be granted any access to the PAR
Patient Portal patient record unless the patient provides consent to access.
Restricted access to another adult’s information will be granted upon request from the patient. If the
individual has diminished capacity, full access will be granted to the healthcare agent or legally
authorized representative.
Please read carefully. Your acceptance indicates that you have read, understand, and agree to these
Terms and Conditions of Use.
1. I will not share my confidential login credentials with anyone else for use to access the patients PAR
Patient Portal. I understand the importance of keeping my login credentials confidential for the safety of
my child’s private health information.
2. Pediatric Associates of Richmond is not to be held liable for any unauthorized access to a patient’s
health information that may result from you not protecting your access credentials.
3. I understand that the Patient Portal is not to be used in emergency situations. If there is a medical
emergency or an urgent medical question, I will contact Pediatric Associates of Richmond directly or call
911.
4. I understand that any activities within the PAR Patient Portal completed by the Proxy, (myself) may be
tracked by computer audit and that any entries and messages may become part of the medical record.
5. I understand that as a Proxy, I will receive an email notification any time new information is available
in the patient’s Patient Portal. The notification itself does not contain any medical information, however,
I understand that if I do not want to continue receiving these notifications, I can select the
“Unsubscribe” option at the bottom of any Patient Portal email to stop further notifications.
6. I understand that access to the PAR Patient Portal is provided as a convenience to patients and that
Pediatric Associates of Richmond has the right to deactivate my Proxy Portal access at any time for any
reason or for no reason.
7. I understand that my use of the PAR Patient Portal is voluntary and that I am not required to use the
Patient Portal for myself or as a Proxy on behalf of another patient.

By signing this form, I confirm all the representations and warranties above, and I hereby accept the
duties and responsibilities of being granted access to medical information.

By signing this, I acknowledge that I have read and accept the Terms and Conditions of this form.

Signature(Required)

Date(Required)