Client Portal Proxy Form Ages 18 and above Mental Health Proxy From for ages 18 and olderA proxy authorization means that you give another person full access to your Credible Client Portal medical record through an online Client Portal account. It is as if they were you. This might be a parent or guardian who helps you take care of your health. You must complete the entire form.Adult Information (Client giving proxy access)To allow proxy access those 18-years old and older MUST CONSENT TO THIS FORM BELOW IN ORDER FOR THIS INFORMATION TO BE PROCESSED. All information MUST be filled out, if any information is missing, this will delay process:Date MM slash DD slash YYYY Client Name First Last Date of Birth MM slash DD slash YYYY AgeAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone:Parent/Guardian (person requesting access):All information MUST be filled out or it will delay request.Name of Parent / Guardian Requesting Access: First Last Address of Parent / Guardian Requesting Access: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth MM slash DD slash YYYY Phone:Email Address to send verification code: Last four digits of SSN for child you are registering:Legal relationship to client:For parents/guardians who are divorced, separated and/or share custody of the minor child you, the parent asking for proxy rights, MUST show legal documentation indicating that you can have access to the child’s medical/mental health care.Northland Counseling Center, Inc. can release health information for the client to the proxy listed above through an online Client Portal account.Client Portal Agreement:Consent: I have read and understand the following:• For adults 18-years old and older, if the adult client does not indicate consent to this form, the proxy will not be given access to their Client Portal medical record. • For adults 18-years old who provide consent to this form, the proxy will have full access to your Client Portal medical record for one year. The proxy will need to fill out a new authorization form each year to renew access. • Adults 18-years old can change their mind about proxy access to Client Portal at any time by letting Northland Counseling Center, Inc. know in writing; unless the proxy has legal guardianship over the client. When Northland Counseling Center, Inc. gets the note, the change will be made no later than 3 business days. The change will not apply to information that has already been released before the effective date. • For parents/guardians who are identified as a legal guardian and the adult client is over 18-years old; the legal guardian asking for proxy rights, MUST show legal documentation indicating guardianship. • Patient Proxy Authorization ends one year after the form is signed/dated. • Northland Counseling Center, Inc. cannot be responsible for the privacy of information given to the proxy. Northland Counseling Center, Inc. cannot prevent the proxy from giving information to another person. At that time, the information is no longer protected by federal and state privacy rules. • If I do not consent to this form, Northland Counseling Center, Inc. will still provide treatment to the client. This form will not affect payment, enrollment, and eligibility for benefits. • You must complete, sign and/or consent, and date this form for it to be valid. A photocopy, fax or electronically scanned and transmitted image is the same as the original. • You can have a signed copy of this form, at your request. • For the proxy to gain access to your Client Portal account, the proxy must activate the account with the code they will be given. The proxy must confirm that they have read and agree to the Northland Counseling Center, Inc. Client Portal Terms and Conditions. These Terms and Conditions apply to each use. • I understand additional medical records may be requested through the Northland Counseling Center, Inc. Medical Records Office Attestation We attest that we are the individuals identified on this document and we agree to the information outlined above.I consent to giving proxy access to the person identified above. If this box is not checked, proxy access will be denied. Please of the client sign the form below.
