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Patient Portal Request Form

 

Choosing the location where you received treatment is essential for providing access to your records. If you know the email you provided at the time of your visit or have your medical record number; you may self-enroll from your computer or mobile device by entering the required information. Please allow 1 - 2 business days to receive an activation link to the email provided below to activate your account.

Location of Service

Patient Information

Access to Someone Else's Records? (i.e. Child)

Please Include Image of Valid Government Issued ID

I understand that my health information is protected by federal and state law. This consent applies to records which may contain information related to the testing, diagnosis or treatment for conditions including, but not limit to, drug and alcohol abuse; psychotherapy, mental or other behavioral health; HIV/AIDS or other communicable diseases; genetic testing; or any other condition expressly protected by Florida Law. This consent will remain in effect unless I deactivate my account or withdraw my consent, in writing, to Broward Health. I understand that my username and password will be unique to my health information and sharing my username and password may grant others access to my health information. I further understand that any health information disclosed as a result of sharing my username and password may no longer be protected under federal or state law and could be further released by the individual who receives the information. I understand that I may refuse to sign this consent and such refusal will not prohibit me from receiving treatment, payment for my treatment, enrollment in a health plan, or eligibility for benefits. I further understand that my refusal to sign this consent will not prevent me from receiving a copy of my medical records.