Parent Proxy Portal Sign Up Form - Pediatric Associates of Richmond

PAR Proxy Portal Sign Up

Please complete all fields on this form to gain access to PAR’s patient portal as a proxy for your child(ren). *If your child is between the ages of 13-17 yrs and wants to have their own Portal access, please have them complete the Self Portal Proxy 13-17 yrs consent form.

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This field is for validation purposes and should be left unchanged.

Proxy's Name(Required)

First Last

Relation to child(ren)(Required)

Primary Phone Number(Required)

Email(Required)

Proxy's Name

First Last

Relation to child(ren)

Primary Phone Number

Please activate me as the Proxy for each of the following children for PAR's Patient Portal

Include each child’s information

Child's Name(Required)

Child's Date of Birth(Required)

Child's Age(Required)

Child's Name

Child's Date of Birth

Child's Age

Child's Name

Child's Date of Birth

Child's Age

Child's Name

Child's Date of Birth

Child's Age

Child's Name

Child's Date of Birth

Child's Age

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.

You are accessing the PAR Patient Portal of the child in which you have been granted Proxy access.

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.
– If your child is age 0-12, parent/legal guardian will be granted full access to the child’s PAR Patient Portal record.
– If your child is age 13-17, parent/legal guardian will be granted partial access (restricting lab results and office notes)
to the child’s PAR Patient Portal record.
– Once your child reaches 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.

Full 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 understand that I have been granted Proxy Access to a minor or other individual’s PAR Patient Portal. I understand the
Proxy Patient Portal access I have been granted will be either complete or limited/restricted dependent on the patients age if
they are a minor. I understand that granting proxy access to a third party is completely voluntary.
2. I will not share my confidential login credentials with anyone else for use to access the patient’s PAR Patient Portal. I
understand the importance of keeping my login credentials confidential for the safety and privacy of the patient.
3. Pediatric Associates of Richmond is not to be held liable for any unauthorized access to the patient’s health information that
may result from you not protecting your access credentials.
4. 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.
5. 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.
6. 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.
7. 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.
8. 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.
9. As the Proxy, I have read and understood the requirements for accessing the patient’s Patient Portal account information
and agree to abide by the according terms and conditions.

By digitally signing this form, I confirm all the representations and warranties above, and as the Proxy user, I hereby accept the
duties and responsibilities of being granted access to the patient’s medical information.

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

Signature(Required)

Date(Required)