Consent for Access to Protected Health Information (PHI)

Who will be filling out this form?*

Patient / SelfLegal Representative

Patient Full Name*

Date of Birth*

The Bridge and the Patient Portal are HIPAA compliant communication and health record systems where you and/or people you authorize can stay updated or access important health information online and access the Bluestone care team anytime. Both are very important tools for delivering high quality healthcare and keeping everyone informed. The primary way to reach your provider team is through the Bridge!

If patient is signing this form: I can authorize a personal representative to access my health care information and communicate with my Bluestone Provider Team electronically through the Bluestone Bridge and/or the Bluestone Patient Portal by filling out the PHI form with the appropriate information.

If Legal Representative signing this form: I acknowledge and agree that by signing this form as a Legal Representative for the patient, I swear and attest that I am legally authorized to act and make decisions on behalf of the patient. I am required to provide a copy of valid and effective documentation outlining my role as
Legal Representative in order to receive related communications. Upon signing the form or any other required documentation from Bluestone as a Legal Representative for the patient, I hereby release and hold harmless Bluestone Physician Services and its representatives from any claims or damages arising from Bluestone’s reliance on my attestation that I am Legal Representative.

If you are the Legal Representative for someone who is not able to consent themselves, you will need to fax or upload this form and the supporting legal documents (Health Care Directive, Healthcare Power of Attorney forms, proof of guardianship, etc.) to our office as soon as possible. Receiving this paperwork is the only way we can provide access to Protected Health Information to someone other than the patient.

This consent applies to health information Bluestone already has about me, information about future care I may receive from Bluestone and information Bluestone receives from third parties. This consent will continue unless I cancel by giving written notice to Bluestone Physician Services or it expires as required by law. Cancellation will apply after the date when the notice to cancel is received. It will not affect information that used or disclosed before cancellation.

People who the signer of this consent grants access to Bridge and Patient Portal: (Note: First Name, Last Name, Email, and Phone number are required for Access) *

	Name	Email Address	Phone Number	Relationship to Patient
Person 1
Person 2
Person 3
Person 4
Person 5

REQUIRED: By signing below, you acknowledge the above and that you are giving the following individuals access to your health care records maintained by Bluestone, including updates on your health care status.

(Please Note: If you are signing this document and wish to have access for yourself, please include your First Name, Last Name, Email, Phone # in the above section.)

Patient Signature*

Date*

Date

Legal Representative Signature (if authorized to sign for patient)*

Date*

Date

Verify Signature*

I verify that I have electronically signed above and that my signature is displayed in the signature box.

Legal Representative Printed Name*

Relationship to Patient*

Additional Medical Documents (POA, HCD, Others)