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Patients & Visitors

PHR Release Form

PCRMC requires that all patients complete an authorization form in order for personal information to be released. Fill out the form below and mail, fax or deliver the form to the Health Information Management (HIM) Department. Once this step is completed, the HIM Department will validate the request and an email will be sent to the patient's email account. The email will contain a link that will connect the patient to the HealthVault™  account. Once you are in HealthVault™, please complete the following steps.

  1. Once the email has been received, click the embedded link to start the process.
  2. You will be prompted to enter the answer to the security question you submitted when you initiated the link with PCRMC.
  3. Confirm the profile you want the information linked to and verify that you want to link to PCRMC.

Click here to download the PHR Release form.

Important Notes:

  1. All statements on the authorization requiring initials must be initialed for all patients in order for information to be linked to the HealthVault™  PHR.
  2. Minor patients that are between the ages of 13 to 17 must co-sign the authorization. Patients in this age range may have information that is protected from their parents; however, by co-signing the authorization they are authorizing and noting they are aware that this information may be viewed in their PHR by their parents.
  3. The authorization must be signed within six months of submitting to the HIM Department for linking.