Portal Authorization for Hospital Clinics

Patient Name(Required)

First Last

DOB

Age(Required)

Patient Address(Required)

Street Address City State Zip Code

Parent/Guardian Name

First Last

(if patient is under 18)

Parent/Guardian Email

DOB

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

First Last

Proxy Email

DOB

Please securely release my information to the:

Clinic Portal (Follow My Health Patient Portal)

Hospital Portal (CPSI Patient Portal) **Available for patients ages 18 and over**

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.

Patient or Authorized Representative Signature:

Date

Patient or Authorized Representative Name

First Last

Patient Identification Verified

For Office Use only

Portal Authorization for Hospital Clinics

For adult patients if requested

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Portal Authorization for Hospital Clinics

** For adult patients if requested **

Subscribe

Explore

Services

Finance

For adult patients if requested