HealthConnect Registration Form 1 Terms of Service2 Your Information HealthConnect Access Request - Terms of Service I request access to Wise Health System HealthConnect. I understand that Wise Health System HealthConnect will let me: Communicate with the participating doctors, nurses and other support staff (“healthcare providers”) listed on Wise Health System HealthConnect, including asking for prescription refills and appointments to see my healthcare providers. See portions of my health information. Have future access to more types of information and communications. I AGREE: I agree to promptly log into the Wise Health System HealthConnect to set up my own personal account. Wise Health System Health will email me a link that will take me to the Wise Health System HealthConnect and require me to enter my unique validation code that was given to me. The validation code is only usable for first the time when I enter in to the Patient Portal. Once I get in to Wise Health System HealthConnect I will set up my own unique user ID and password. I agree to read carefully the Wise Health System HealthConnect Terms and Conditions of Use that I will see when I log in to Wise Health System HealthConnect. The Terms and Conditions of Use is a contract about how Wise Health System HealthConnect services are provided to me and used by me. I agree to use Wise Health System HealthConnect properly as it is intended to be used. Proper use includes making sure that I select the correct recipient so that my messages will get to the correct person. If I change my email address, I will log in to my Portal account and self-service change my e-mail address inside the section labeled User Information under the Profile menu selection on my Portal home page. I understand that any messages sent via the Wise Health System HealthConnect may be included in my medical record. If I want to stop all messages through Wise Health System HealthConnect or with a particular healthcare provider, I agree to send a message via Wise Health System HealthConnect to my practice requesting that I want to be removed from Wise Health System HealthConnect. I understand that if I do this, I will no longer be able to use Wise Health System HealthConnect and my account will be closed. Once my messages are received by the healthcare provider I have selected, either the healthcare provider or healthcare provider’s staff who is assigned to help manage such messages may read them. Wise Health System HealthConnect messages with a healthcare provider are not for emergent or urgent health care needs nor are they a substitute for examination and treatment by the healthcare provider. I agree not to share my user name and password to Wise Health System HealthConnect with anyone. Wise Health System HealthConnect is not for emergencies or urgent care. If you have a medical or psychiatric emergency you must call 911 immediately or go to the nearest hospital. Name* First Last Middle NameDate of Birth* MM DD YYYY Last 4 digits of SSN#*Driver License NumberGender*FemaleMaleAddress*City*State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZipcode*Phone Number*Secondary Phone NumberYour Email Address* Enter Email Confirm Email Your Signature*Please type your full name.10/26/2020By clicking “Submit”, I certify that I, as the enrollee, have read, understand and agree to the terms and conditions in the Patient Portal Access Request on the previous page and intend this to be my legally binding signature.CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.