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Patient Mgmt Portal Request form



This system gives you access to your patients' diagnostic images and reports as well as scheduling exams via the Internet. The first step in accessing this system is to obtain your secure username and password by completing this form. Please include a business phone number that can be verified. If you do not receive an acknowledgment email within 2 business days please call 602.521.6373.

As healthcare providers, we are bound by the Health Insurance Portability and Accountability Act (HIPAA) to protect patient protected health information (PHI). SMIL Medical Imaging is dedicated to maintaining strict compliance and adhering to all privacy standards set forth by HIPAA rules and regulations.


In using SMIL Medical Imaging's Patient Management Portal, you hereby agree to use protected health information (PHI). This site is intended for authorized physician and/or healthcare provider use for the sole purpose of treating and diagnosing your patient(s) only and for no other purpose except those allowed by federal and state laws.

By submitting this form you also agree to:

SMIL Medical Imaging reserves the right to monitor the usage of this system to ensure this service remains available to authorized users. To ensure the data transmitted between you and SMIL Medical Imaging is not viewed by unauthorized users, this website is encrypted. Any attempt to modify this program or associated information is strictly prohibited under the Computer Fraud and Abuse Act of 1986.

SMIL Medical Imaging reserves the right to terminate this agreement and use of upon making the determination that there has been a violation or breach of the terms and conditions of this agreement. This allows us to reserve the right to monitor usage which includes, but is not limited to, audit logs/trails. Any covered entities or individuals found to have divulged or allowed unauthorized disclosure of patients' PHI may have their access terminated and may be reported to Office for Civil Rights (OCR). Failure to comply with HIPAA requirements can result in civil and criminal penalties. These civil and criminal penalties can apply to both covered entities and individuals.


SMIL Medical Imaging requests only such personal information necessary to verify your identity and create secure access. We may revise or update this statement to remain in compliance with security and privacy laws. Your continued use of these sites constitutes your agreement/acceptance to these revisions. If you do not agree to the conditions set forth in these statements, please discontinue use of this site immediately and notify the privacy officer at


Listing providers in your practice allows you to view their individual patient worklists and to enable them to order online

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