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Electronic Data Access Consent

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Electronic Data Access Consent

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Hixny Electronic Data Access Consent Form Open Door Family Medical Centers

All fields marked with * are required.

Please Select One:

Dental Care
Medical Care

*Office Location

Ossining Dental

Port Chester Dental

Sleepy Hollow Dental

Mamaroneck Dental

Brewster Dental

School Based Health Center Dental

Saugerties Dental

Mt Kisco Medical

Ossining Medical

Port Chester Medical

Sleepy Hollow Medical

Mamaroneck Medical

Brewster Medical

School Based Health Center Medical

Saugerties Medical

Please carefully read the information on both pages of this form before making your decision.

*You have two choices:

I GIVE CONSENT for Open Door Family Medical Center to access ALL of my medical records through Hixny in connection with providing me any health care services, including emergency care.

I DENY CONSENT for Open Door Family Medical Center to access my medical records through Hixny for any purpose, even in a medical emergency. Unless you check this box, New York State law allows medical providers treating you in an emergency to get access to your medical records, including records that are available through Hixny.

*Patient Name:

*Date of Birth:

*Signature of Patient or Patient's Legal Representative:

Please sign in the box below using your mouse, touch screen, or touchpad.

Clear Use Most Recent Signature

I accept that this is the legal representation of my signature.

*Date:

Print Name of Legal Representative (if applicable):

Relationship of Legal Representative to Patient (if applicable):

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Type To Sign

Type Your Name: Type Your Name is required.

Choose your style that match your handwriting:

Your singnature will appear as follows:

By selecting "Accept & Sign", I agree that the signature above is a legally binding electronic version of my signature for all user within the scope of these documents, equivalent to my paper signature.

Electronic Data Access Consent

Hixny Electronic Data Access Consent Form Open Door Family Medical Centers

Please carefully read the information on both pages of this form before making your decision.

Type To Sign

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