Forms for Students - Portage Health

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Forms for Students and Their Families

Having to manage your health on your own can be nerveracking. Many of you are legal adults now. In order for your parents or guardians to access your health information, you need to grant your consent. Completing the following forms will allow your family to have access to your health information while you are away at college.
Acknowledgement of Reciept of the Notice of Privacy Practices of Portage HealthComplete this form to acknowledge that you receive and understand the Notice of Privacy Practices of Portage Health.
Authorization for Use and/or Disclosure of Protected Health InformationUse this form to authorize Portage Health Medical Group to send your Protected Health Information to an individual or institution (such as another health care provider).
Authorization to Dislcose Medical InformationUse this form to authorize Portage Health Medical Group to disclose medical information about your health care to specific individuals.
Outpatient Authorization for Examination and Medical TreatmentUse this form to consent to examination and medical treatment by Portage Health Medical Group clinical staff for yourself or for a minor for whom you are a parent or legal guardian.

Forms for Students and Their Families