Portal Authorization for Hospital Clinics

Patient Name(Required)
Patient Address(Required)
Parent/Guardian Name
(if patient is under 18)

** For adult patients if requested **

I consent to have the following person named as a proxy and to have access to my medical records (example: you may give your spouse/adult children/etc. permission to view your medical records)
Proxy Name
Please securely release my information to the:
I authorize Woodlawn Hospital to release my medical information securely on the Patient Portal on Woodlawn Hospital’s website (www.woodlawnhospital.com).

*Ages 14-17 are considered a young adult - only secure messaging and historical information are available. No updated health information will be added to the patient’s health record due to Privacy and Confidentiality Laws.
MM slash DD slash YYYY
Patient or Authorized Representative Name
For Office Use only
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