Woodinville Pediatrics

By checking the box and signing below, I acknowledge that I have read, understand and agree to the following Seattle Children’s and Woodinville Pediatrics Clinic, PLLC’s terms and conditions.

As parent, legal guardian or legal custodian of the above-named patient, I understand that Woodinville Pediatrics Clinic, PLLC shares an integrated electronic medical record with Seattle Children’s Hospital. I also understand the general policy of Woodinville Pediatrics PLLC and SCH is to not disclose my child’s Protected Health Information (PHI) to others without my consent unless they are directly involved in my child’s care, or as permitted or required by law. (To sign up for access to your child’s health information via MyChart, you must have a MyChart account and parent or legal guardian must sign this consent.)

I understand and agree that:

• I am authorizing access to all health information contained within MyChart, which may include sensitive health information, including but not limited to information about the following: 
  • Sexually transmitted infections/HIV 
  • Behavioral/mental health
  • Developmental disabilities
  • Drug/alcohol use and abuse 
  • Genetic testing and counseling and
  • Reproductive care and treatment. 
• The information obtained via MyChart is not the complete medical record, and an individual with legal right to obtain information from the patient’s medical record will be required to submit a separate Authorization to Release/Obtain/Exchange Patient Health Information if they want Woodinville Pediatrics to provide to the proxy identified above additional information from the medical record.
• This Access Agreement will continue until revoked, and I may revoke it at any time by contacting the Medical Records department via one of the methods listed at the bottom of this form
• Woodinville Pediatrics may discontinue a proxy’s access to MyChart at any time 
• Woodinville Pediatrics will not condition treatment of the patient, payment, or other services on my signing of this Access Agreement form.
• I can contact Medical Records at 425-483-5437 if I have questions about this form

I have read and understand the information contained within this Access Agreement form. I understand and agree to its terms and hereby designate the above-named person as a MyChart proxy, thereby allowing them access to all information contained within the patient’s MyChart account that Woodinville Pediatrics provides to proxies consistent with federal and Washington State privacy laws. I hereby release Woodinville Pediatrics, its employees, trustees, officers and agents from any legal responsibility or liability for disclosure of the information contained in the patient’s MyChart account, to the proxy that I have specified.

The legal representative is the patient’s decision maker with current authority. It can be the designated caregiver, healthcare power of attorney, healthcare proxy, or other designated person or third-party entity designated by law. Additional documentation may be requested to verify the relationship and/or representation