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By using this form, you are requesting that Endwell Family Physicians email your representative the activation code to your portal so that your representative can access your patient portal. Giving another person access to your patient portal means that that person will have access to your medical records. You should only give another trusted person this access where you feel it is necessary for your healthcare.
This form is only for use where you are requesting another person, your representative, to have access to your portal. If you want to receive access yourself to your own portal, then please complete the Patient Portal Activation Code Request Form – Patient.
By signing this form, you indicate that you understand that email may not be secure. This means that there may be a risk to you that the information contained in the email could be intercepted and read by a third party. By signing this form, you indicate that you accept those risks and want EFP to email you your portal activation code. You understand that EFP will not use this consent to email any information other than your portal activation code.
To further protect the security of your account, EFP will use only email the activation code to an authorized representative if the person you list below is also listed on the Family Info Authorization that we have on file in your medical chart.
To send your authorized representative the portal activation code, EFP needs the following information:
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