“Patient Online” Access Request


1.        I hereby request that The George Washington University Medical Faculty Associates (MFA) permit the individual identified herein to access my private and confidential health information through the MFA website: www.Gwdocs.com.


2.        I understand that I can revoke this authorization at any time, by _______.  I recognize that unless I revoke my permission, this individual will have continuous access to all of the information that is accessible through the Patient Online website and all personal information that can be accessed with my username and password.


3.        I recognize that any revocation that I make will not effect access to my personal information prior to my request for revocation.


4.        I agree to assume responsibility for all costs incurred by the individual to whom I have granted access to my Patient Online information associated with his/her use of the GWDocs Website.


5.        This release does not alter my prior agreements regarding the use of the GWDocs Website.


6.        By signing below, this individual also agrees to be bound by all of the terms of use, privacy statements, and other agreements associated with Patient Online.


7.        I understand that this agreement does not prevent me from accessing my patient information, appointment systems, or prescriptions through other mechanisms made available to me through the Medical Faculty Associates (MFA).


8.        I hereby release The George Washington University Medical Faculty Associates (MFA), and its employees, officers and physicians from any and all liability for the disclosure of personal health information made in accordance with this request, including any subsequent unauthorized disclosure(s) made by the individual I have authorized to access my personal information.



__________________________________                                 ____________________________________

Patient Signature                                                                                  Individual Requesting Permission


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Printed Name                                                                                        Printed Name


__________________________________                                 ____________________________________

Date                                                                                                        Date


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Social Security Number                                                                       Relationship



Date of Birth