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Bothwell patient portal

Bothwell patient portal 2026

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4.2 out of 5

50 votes

The document is an authorization form for patients at Bothwell Regional Health Center to grant access to their patient portal to a designated proxy. It outlines the patient's consent for the proxy to view their personal health information and specifies that this authorization remains valid until revoked. Additionally, it includes an option for patients to decline access to the patient portal while allowing for future enrollment.

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Click ‘Get Form’ to open the Authorization/Declination for Access to Patient Portal in the editor.
Begin by entering your Patient Name, Date of Birth, Email Address, and Phone Number in the designated fields. Ensure all information is accurate for seamless access.
If you wish to authorize a proxy, fill in their Proxy Name, Date of Birth, Phone Number, and Address. This individual will have access to your health information through the portal.
Review the authorization statement carefully. By signing, you grant your proxy access to your personal health information as outlined.
If you choose to decline access, simply check the box provided. Remember that this decision can be changed later if desired.
Finally, ensure all signatures are completed where required: Patient, Parent/Guardian (if applicable), and Proxy. Save your document once finished.

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Versions	Form popularity	Fillable & printable
2020	4.6 Satisfied (40 Votes)
2019	4.2 Satisfied (50 Votes)

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