Pa atient Portal Authoriza l ation Form

By signin this docum I agree to abide by the ethical and legal res ng ment e y sponsibility to protect th he confident tiality of hea records. I agree to u the patien portal onl to access m own hea alth use nt ly my alth records, a and/or those of my own minor child e dren or those for whom I am the dura power o able of attorney for health ca are. If I beco aware o a breach o this confid ome of of dentiality, fo whatever or reason, I will report it to Heart of the Valley immediately i f y. dge portal is inte ended as a co onvenient se ervice, and not a replacem ment Further, I acknowled that this p for in-per rson health care. I understand that it is inapprop c t priate and da angerous to u this porta for use al emergenc diagnosis for treatment. For noncy s -emergent is ssues, if I do not receive a response within th expected time-frame, I agree to co he t ontact Heart of the Valley by conven ntional mean ns, such as b phone or in person. by i Should I, for whateve reason, ga access to another per , er ain o rsons health records, I a h agree to not r read such info ormation and I agree to r d report the pro oblem imme ediately to H Heart of the V Valley. I underst tand that I ha a responsibility to pr ave rotect my ow log-in and password i wn d information, and , that Hear of the Vall will not b held liabl for breach of confid rt ley be le hes dentiality aris sing from unauthor rized use of such informa s ation.

Signature of Patient/ Legal Guardian/ Durab Power of Att f G ble torney for Health Care h

Print Patients name

E-mail addr (please print legibly) ress t

Please return completed form to He P n d eart of the V Valley by fa mail or in person. ax,

Andrew J. Maxwell, M . M.D. FAC CC Ped diatric Cardi iologist 5933 Coro onado Lane, S Suite 1F, Plea asanton, CA 9 94588 Fax 925 397-2193 x email: amaxwell@h : heartofthevall ley.us Brentwood Fremont Lafayette e Tracy y San M Mateo

Phone 92 416-0100 25 on Pleasanto