CHILD PROXY FORM - Southwest Diagnostic Imaging Center

 CHILD PROXY FORM
Access to Your Child’s Patient Portal Record
To sign up for access to your child’s Patient Portal record, please complete both pages of this Child Proxy
Form and return it to the address shown below. Please note that your child’s chart will be accessed
through your Patient Portal record. Completing this form will establish a Patient Portal record for you and
your child.
Please return the form to:
Support Systems/Health Information Mgmt.
Southwest Diagnostic Imaging Center
8230 Walnut Hill Lane, Suite 100
Dallas, TX 75231
[email protected] or Fax to: 214-345-6519
Mother or Guardian Information: (All fields required except as noted – please print clearly.)
Name (Last, First, Middle Initial)
Date of Birth:
Email Address:
Street Address:
City:
State:
Zip:
Phone Number:
Social Security Number (last 4 digits) XXX-XXFather or Guardian Information: (All fields required except as noted – please print clearly.)
Name (Last, First, Middle Initial)
Date of Birth:
Email Address:
Phone Number:
Social Security Number (last 4 digits) XXX-XX Check box when address is the same as above
Street Address:
City:
State:
Zip:
Please provide the following information for each child. All fields are required. If you have more than
four children for whom you would like proxy access, please request another form or print another
form from one of our websites. Please note that children must be a previous patient at Southwest
Diagnostic Imaging Center (SWDIC) or Southwest Diagnostic Center for Molecular Imaging
(SWDCMI) in order for proxy access to be setup.
1. Name (Last, First, Middle Initial)
Date of Birth:
2. Name (Last, First, Middle Initial)
Date of Birth:
3. Name (Last, First, Middle Initial)
Date of Birth:
4. Name (Last, First, Middle Initial)
Date of Birth:
Created 8/23/16
8196 WALNUT HILL LN, STE LL30
DALLAS, TEXAS 75231-7227
214.345.8300  www.swdcmi.com
THD PROFESSIONAL BUILDING 3
8230 WALNUT HILL LN, STE 100
DALLAS, TEXAS 75231-4472
214.345.6905  www.swdic.com
Patient Portal Terms and Agreement

I understand that this Patient Portal is intended as a secure online source of confidential medical
information. My Patient Portal Login ID and Password cannot be shared with anyone, because that
person will be able to view my or my child’s health information. This action can result in revocation of
Patient Portal access to my records and my child’s records.

I understand my Patient Portal Login ID is my email address and that keeping my Login ID secure
depends on two additional factors:
1) It is imperative that this practice has my correct email address and that I inform them of any
changes to my email address.
2) I also need to keep track of who has access to my email account so that only I, or someone I
authorize, can see the messages I receive from this practice. I am responsible for protecting
myself from unauthorized individuals learning my password. If I think someone has learned my
password, I should promptly go to the website and change it.

I agree that it is my responsibility to select a confidential password, to maintain my password in a
secure manner, and to change my password if I believe it may have been compromised in any way.

I understand that the Patient Portal contains selected, limited medical information from a patient’s
medical record and that patient medical records may be requested from Southwest Diagnostic
Imaging Center and/or Southwest Diagnostic Center for Molecular Imaging.

Once my child reaches age 18, I will no longer have access to my child’s Patient Portal record, unless
they process an Adult Proxy Form for authorization.

I understand that my activities within the Patient Portal may be tracked by computer audit and that
entries I make may become part of the medical record.

I understand that access to the Patient Portal is provided by Southwest Diagnostic Imaging Center
and Southwest Diagnostic Center for Molecular Imaging as a convenience to its patients and that
SWDIC and SWDCMI has the right to deactivate access to the Patient Portal at any time for any
reason. I understand that use of the Patient Portal is voluntary, and I am not required to use the Patient
Portal or to authorize a Patient Portal Proxy.

By signing below, I acknowledge that I have read and understand this Patient Portal Sign-Up Form and
I agree to its terms.
 Mother  Guardian
Signature of Mother or Guardian (Required)
Relationship to Patient (Required)
Signature of Father or Guardian (Required)
Relationship to Patient (Required)
 Father
8196 WALNUT HILL LN, STE LL30
DALLAS, TEXAS 75231-7227
214.345.8300  www.swdcmi.com
Date (Required)
 Guardian
Date (Required)
THD PROFESSIONAL BUILDING 3
8230 WALNUT HILL LN, STE 100
DALLAS, TEXAS 75231-4472
214.345.6905  www.swdic.com