Consent for Access to Protected Health Information (PHI) via the Bluestone Bridge and Bluestone Patient Portal

Consent for Access to Protected Health Information (PHI) via the Bluestone Bridge and Bluestone Patient Portal
Who will be filling out this form?
Patient Full Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
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. The Bluestone Bridge allows members of the patient’s care team to exchange medically relevant messages between regular visits. The Patient Portal is a separate platform allowing additional access to personal health information.
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)

Rows	Name	Email Address	Phone Number	Relationship to Patient
Person 1
Person 2

REQUIRED: By signing this form, you acknowledge the information provided herein and request access to the Bluestone Bridge and Bluestone Patient Portal for you or a legal representative as well as (optionally) an additional designated individual. Access to these systems includes patient Protected Health Information records as maintained by Bluestone Physician Services, including the ability to view updates on health care status and the ability to communicate with the assigned Bluestone care team.
Patient Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Legal Representative Signature (if authorized to sign for patient)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Verify Signature
Legal Representative Printed Name
Relationship to Patient
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.
Additional Medical Documents (POA, HCD, Others)

Cancelof
Should be Empty: