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