Horn Memorial Hospital Patient Portal Disclosure Horn Memorial Hospital (HMH) is offering access to the InteliChart patient portal as a courtesy to our patients. This web-based patient portal is a secure tool that provides patients the ability to access portions of their medical record. This form is intended to inform you of the facts and risks surrounding the use of a web portal. The HMH InteliChart patient portal is not a replacement for in-person healthcare. It is not appropriate to use this portal for emergency diagnosis or treatment. HMH Health Information Management (HIM) Policy and Procedures regarding the patient portal: 1. Patients may have electronic access to certain portions of their health information, such as medical history, medications, and lab results, through a secure website. Certain results of a sensitive nature may not be viewable in the portal. 2. You may enroll in the portal either via the website under the “Create an Account” tab or in person at HMH’s HIM Department. In person identification verification at the HIM Department will be required prior to access being granted to the portal. https://hornmemorialhospital.intelichart.com/PatientPortal/account/login 3. Parents and legal guardians may be granted access to records of minor children up to the age of 13. Due to Iowa Law (Chapter 141), minors over the age of 13 will need to set up their own access to the patient portal. Sharing of the minor’s patient portal information is left to the discretion of the minor. 4. Adult patients may designate another adult to have access to their portal account as a proxy. a. Patients must complete and sign a Patient Portal Access Consent Form to authorize proxy access, or to revoke proxy access. b. The HIM Department will be responsible for handling all requests to revoke proxy access. Responsibilities of Patient Portal Users: Every authorized portal user has the responsibility to protect the confidentiality of health records. All authorized portal users are expected to keep their portal password secure to prevent any unauthorized access to patient information. HMH is not liable for breaches of confidentiality arising from unauthorized use of such information. If you suspect that someone has learned your password, you should access the portal site immediately and change it. If you become aware of a breach, for whatever reason, you are expected to promptly report it to the HIM Department at HMH at (712) 364-3311. Should you gain access to another person’s health records, for whatever reason, you agree to not read such information and agree to report the problem immediately to the HIM Department at HMH at (712) 3643311. Forms/Health Information/Patient Portal Disclosure Initiated 6/2014 Horn Memorial Hospital Patient Portal Request Form  I am requesting access to Horn Memorial Hospitals InteliChart patient portal for my own information. Patient Name Birthdate Mailing Address Email Address **Note if this email address is not unique to you, others may see/access the information regarding the patient portal. Access to Minor Child’s Information  I am requesting access to Horn Memorial Hospitals InteliChart patient portal for my child’s information. Patient Name Birthdate Mailing Address Email Address **Note if this email address is not unique to you, others may see/access the information regarding the patient portal. Proxy Access  I would like to grant someone else access to my information via the patient portal. Proxy Name Relationship to Patient Email Address of Proxy Revocation of Proxy Access  I would like to revoke proxy access to my information via the patient portal. Email Address of Proxy By signing below, I confirm that I have read the Horn Memorial Hospital Patient Portal Disclosure and agree to comply with the procedures and guidelines for using the Patient Portal. Signature Forms/Health Information/Patient Portal Disclosure Date Initiated 6/2014