Howard County Medical Center : Patient Portal : Patient Portal

Personal Information

Authorization for Patient Proxy Access

If you would like to access the portal for someone other than yourself, this form needs to be completed and returned to our Medical Records department.
Download Patient Proxy Form

I'm a return user
Click on the following line to access a text only version:
Web Content Accessibility Guidelines (WCAG).

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First Name (Required)

First Name

Last Name (Required)

Last Name

Middle Intial

Middle Intial

Email Address (Required)

Email Address

Phone Number (Required)

Date of Birth

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Last 4 digits of your social security number (Required)

Last 4 digits of your social security number