[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-565494-105":53,"doc-detail-565494-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","connect-patient-portal-proxy-access-authorization","Connect Patient Portal Proxy Access Authorization","","Connect Patient Portal Proxy Access Authorization form for Weill Cornell Medicine, NewYork-Presbyterian, and Columbia University participants in an Organized Health Care Arrangement (OHCA). Grants a designated portal proxy access to the patient’s medical information within the Connect patient portal and explains voluntary consent, limits of information, and conditions for sharing credentials. Describes the effect of revocation, re-disclosure risk under privacy rules, and renewal requirements for adolescent patients aged 12–18 every two years.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/connect-patient-portal-proxy-access-authorization/565494/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/connect-patient-portal-proxy-access-authorization/565494.png","ImageObject",442,249,{"name":88,"@type":89},"aboduw","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-16","2026-10-13",true,{"@type":98,"interactionType":99,"userInteractionCount":9},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What does this authorization allow a portal proxy to do?","Question",{"text":108,"@type":109},"It allows the designated proxy to access the patient’s medical information through the Connect patient portal.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Is authorizing proxy access required for treatment?",{"text":113,"@type":109},"No. The form states authorization is voluntary and treatment will not be conditioned on the disclosure.",{"name":115,"@type":106,"acceptedAnswer":116},"How can the patient revoke proxy access and what happens afterward?",{"text":117,"@type":109},"The patient can revoke the authorization in writing to the OHCA. Revocation terminates the proxy’s Connect account access, but it does not affect actions taken before the revocation is received.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},565494,1792122845,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":9,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":4},3985747862266,"https://ap-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45","Connect Patient Portal Proxy Access Authorization  \nWeill Cornell Medicine, NewYork-Presbyterian, and Columbia University participate in an Organized Health Care Arrangement (OHCA) . This allows us to share health information to carry out treatment, payment and joint healthcare operations relating to the OHCA, including integrated information system management, health information exchange, financial and billing services, insurance, quality improvement and risk management activities.  \nThis form is an authorization to grant an individual portal proxy access to your Connect account. It will permit your designated proxy to access your medical information in your patient portal.  \n Patient Information   \nName of Patient   Date of Birth  / /  Street Address   City   State   Zip    \nEmail   Phone Number    \n Portal Proxy Information –(Name of Person You Designate to Access your Patient Portal Account)  Name of Portal Proxy   Date of Birth  / /  Email   Phone Number    \nRelationship to Patient  \n☐Parent/LAR of Minor ☐Legal Representative  \n☐Spouse/Domestic Partner  \n☐Other    \nTerms and Conditions:  \n􀁸 I understand that Connect is intended as a secure online source of medical information that contains a limited amount of information from my medical record and is not the complete record.  \n􀁸 I understand that this authorization is voluntary and my treatment will not be conditioned upon my authorization of this disclosure.  \n􀁸 I understand that use of Connect is voluntary and I am not required to authorize portal proxy access.  \n􀁸 I understand that if I share my Connect ID and password with another person, that person may be able to view my medical information or the medical information of any person who has authorized me as their Connect portal proxy.  \n􀁸 I authorize the OHCA and their entities to use and disclose my health information and I understand if this information is re-disclosed by the recipient, the released information may no longer be protected by federal privacy regulations.  \n􀁸 If I am an adolescent patient between the ages of 12-18, I understand that I must renew my designee’s portal proxy access every two (2) years.  \n􀁸 I understand that this authorization is valid until I revoke in writing to the OHCA. If I revoke this authorization, my designated portal proxy’s access to my Connect Patient Portal account will be terminated.  \n􀁸 I understand that my revocation will not have effect on the actions taken prior to receipt of the revocation. I acknowledge that I have read and understand the terms stated within this Connect Patient Portal Proxy Access Authorization. I agree to the terms and choose to designate the person named above as my Connect Portal Proxy, thereby allowing them access to my medical information via Connect.  \n     / /   \nPatient Printed Name Patient Signature Date  \nJanuary 2020","cbCairOn2Ad9TDNI","https://ap.wps.com/l/cbCairOn2Ad9TDNI","pdf",542209,"English","# Patient and Proxy Information\n## Terms and Conditions","[{\"question\":\"What does this authorization allow a portal proxy to do?\",\"answer\":\"It allows the designated proxy to access the patient’s medical information through the Connect patient portal.\"},{\"question\":\"Is authorizing proxy access required for treatment?\",\"answer\":\"No. The form states authorization is voluntary and treatment will not be conditioned on the disclosure.\"},{\"question\":\"How can the patient revoke proxy access and what happens afterward?\",\"answer\":\"The patient can revoke the authorization in writing to the OHCA. Revocation terminates the proxy’s Connect account access, but it does not affect actions taken before the revocation is received.\"}]","Connect Patient Portal Proxy Access Authorization | PDF",1791855315]