Steven Wirth, MD, MPH
Please note our new address: 721
S. Dora St.
Ukiah, CA 95482 Tel: (707) 462-3300
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Portal Authorization Form
Steven Wirth MD
750 S. Dora St.
Ukiah, CA 95482 Tel: (707) 462-3300 Fax: (707) 462-3303
Patient Portal Authorization Form
By signing this document I agree to abide by the ethical and legal responsibility to protect the confidentiality of health records. I agree to use the patient portal only to access my own health records, and/or those of my own minor children or those for whom I am the durable power of attorney for health care. If I become aware of a breech, for whatever reason, of this confidentiality, I will report it to Dr.
Wirth’s office expeditiously.
Further, I acknowledge that this portal is intended as a convenient service, and not a replacement for in-person health care. I understand that it is inappropriate and dangerous to use this portal for emergency diagnosis or treatment. For non-emergent issues, if I do not receive a response within the expected
time-frame, I agree to contact Dr. Wirth’s office by conventional means, such as by phone or in person.
Should I, for whatever reason, gain access to another person’s health records, I agree to not read such
information and I agree to report the problem immediately to Dr. Wirth’s office.
I understand that I have a responsibility to protect my own log in and password information, and that Dr. Wirth will not be held liable for breeches of confidentiality arising from unauthorized use of such
information.
_________________________________________________________________
Signature of Patient/Legal Guardian/Durable Power of Attorney for Health Care
_________________________________________________________________
Print Patient’s name (and Signatory if other than patient)
_________________________________________________________________
e-mail address
(please print legibly)
© Steven Wirth, MD 2009
Please return completed form to Dr. Wirth's office by Fax, mail or in person
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