Portal Letter
Authorization for Disclosure of Protected Health Information to Patient Portal

All sections of this form must be filled out completely or it will not be accepted.

I hereby authorize Heartland Women’s Healthcare to use/disclose my individually identifiable health information to Patient Portal (which may include information concerning treatment for drug/alcohol abuse, mental health, HIV status, or genetic testing records, if applicable).

I understand that my health care and the payment of my health care will not be affected if I do not sign this form.

• I understand that I MAY REFUSE TO SIGN THIS AUTHORIZATION. I also understand that Heartland Women’s Healthcare shall not refuse to treat me if I refuse to sign this authorization.

• Heartland Women’s Healthcare is not responsible for a breach of this information if the patient using the portal is using a computer workstation or device that could be compromised.

• I understand that this authorization MAY BE REVOKED in writing and delivered to Heartland Women’s Healthcare 3408 Office Park Dr. Marion, Illinois 62959 at any time requesting that my account be inactivated.

(Typing your name here will be counted as a E-Signature)
By clicking Submit you agree the above information is correct and agree that all signatures are E-Signatures.