Welcome to the Followmy Health Patient Portal

Patient Portal Authorization Form for Mountain Area Health Education Center, Inc. (MAHEC)
MAHEC is pleased to offer our patients the opportunity to access their own confidential medical record by using MAHEC's secure patient portal, Follow My Health. By completing this form, including your signature, and attaching a copy of your photo ID, you are requesting access to the patient portal and authorizing MAHEC to use/disclose your individually identifiable health information to the patient portal. This may include sensitive information such as treatment for pregnancy, drug/alcohol abuse, mental health, HIV status, genetic testing, and labs, if applicable. Patients will only need to complete one form even if they are seen at multiple MAHEC offices.
Authentication Key
Form Type
LEGAL FIRST NAME*
MIDDLE INITIAL
LEGAL LAST NAME*
SUFFIX
ADDRESS*
CITY*
STATE*
ZIP*
DATE OF BIRTH*

MonthDayYear
Date
PHONE*
PERSONAL EMAIL ADDRESS*
example@example.com
Required: Attach a copy of the patient's photo ID*

Cancelof
The patient portal is intended as a secure online means for you to access your confidential medical record information. Please note that if you share your patient portal user name and password with another person, this will allow that person to see your confidential medical record information. MAHEC has no responsibility concerning any breach of your confidential medical record information due to your sharing or losing your user name and password. By signing below you agree to and understand the following:

1. The patient portal is not a replacement for in-person healthcare and I should not use the portal for emergencies or urgent care.

2. Participation in the patient portal is entirely voluntary and I am not required to use the patient portal to receive care from MAHEC. My healthcare and the payment of my healthcare will not be affected if I do not sign this form.

3. I may REVOKE this authorization at any time by providing MAHEC with a written request to inactivate my account.

4. MAHEC is offering access to its patient portal as a courtesy to its patients. MAHEC may suspend or discontinue the service at any time for any reason. MAHEC will attempt to provide the patient portal without interruption, but access is provided on an "as is available" basis. MAHEC does not guarantee that I will be able to access the Patient Portal at any time of my choosing.

5. If I become aware of a suspected breach of my confidential information, for whatever reason, I will promptly report it to MAHEC Risk Management at 828-257-4415. If I, for whatever reason, gain access to another person's health records, I agree to not read such information and agree to report the problem immediately to MAHEC Risk Management at 828-257-4415.

6. I will not use the patient portal in any way that would violate local, state or federal laws, including transmitting materials that are obscene, defamatory, abusive, slanderous or otherwise likely to result in harm to others; distributing viruses; or any other action that could compromise the privacy and security of the system.
Signature*

Clear
Date*

MonthDayYear
Date
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Patient Portal Authorization Form for Mountain Area Health Education Center, Inc. (MAHEC)