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I understand that I have the right to revoke this proxy authorization to my myLoyola Select account at any time. MyLoyola Select Proxy Access Authorization Form Minor to Parent/Adult If you would like an individual such as a parent spouse adult child friend or caregiver to access your Loyola University Health System LUHS myLoyola Select account you must complete the following proxy access form. If the individual does not have a myLoyola Select account an account will be created for him and/or her. I agree to hold LUHS harmless and indemnify LUHS for any damages liability debts fines or attorney s fees that LUHS may incur as a result of my failure to abide by the myLoyola Select Terms and Conditions of Use. LUHS will not condition treatment on my signing or not signing this authorization. I understand that once information is released pursuant to this authorization LUHS cannot prevent the re-disclosure of the information to a third party. its terms and choose to designate the person named above as my proxy thereby allowing him/her to access the personal health information contained in my myLoyola account. I authorize the disclosure of my personal health information to the person identified below. I understand and acknowledge that this may include information related to mental health treatment drug/alcohol abuse treatment HIV/AIDS and/or genetic testing. I understand that if the person s I authorize to receive my personal health information is not subject to federal and state health information privacy laws subsequent disclosure by such person s may not be protected by those laws. I understand that LUHS has the right to revoke this proxy access at any time. Please enter your information* LUHS Medical Record Number Name Gender Male Female Address Date of Birth Social Security Number Phone Number E-mail Please enter proxy s information* I acknowledge that I have read the LUHS myLoyola Select Terms and Conditions of Use. I agree to hold LUHS harmless and indemnify LUHS for any damages liability debts fines or attorney s fees that LUHS may incur as a result of my failure to abide by the myLoyola Select Terms and Conditions of Use. LUHS will not condition treatment on my signing or not signing this authorization* I understand that once information is released pursuant to this authorization LUHS cannot prevent the re-disclosure of the information to a third party. its terms and choose to designate the person named above as my proxy thereby allowing him/her to access the personal health information contained in my myLoyola account. I authorize the disclosure of my personal health information to the person identified below. I understand and acknowledge that this may include information related to mental health treatment drug/alcohol abuse treatment HIV/AIDS and/or genetic testing. I understand that if the person s I authorize to receive my personal health information is not subject to federal and state health information privacy laws subsequent disclosure by such person s may not be protected by those laws..

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