LaheyView Online Access Request Form for Referring Physicians

LaheyView is available to physicians only.

Physician's Last Name *
Physician's First Name *
Physician's Middle Initial
Professional Suffix: * (e.g. MD, DO)
Physician's E-mail *
Specialty *
Practice Name *
Address 1 *
Address 2
City *
State *
Zip Code *
Phone Number *
Phone Extension
Fax Number
Practice Manager *
Practice Manager’s E-mail
Primary Hospital
Secondary Hospital

LaheyView Confidentiality Statement:
Physician agrees that all information received from, read or viewed through use of LaheyView is for treatment purposes and is confidential pursuant to federal and state laws, including but not limited to the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Physician agrees to comply with all federal and state laws concerning such confidential information and agrees to use LaheyView only for those patients with whom he/she has a provider/patient relationship.

Checking this box indicates that you have read and agree to the confidentiality statement above. *

Site Feedback