Adult Proxy Form Access to Another Adult s MyCare Record To request access to the MyCare record of an adult whose medical care you help manage, please complete this form. The patient must sign this.
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How to fill out the Adultproxy online
The Adultproxy form is a critical document for individuals seeking access to another adult's MyCare medical record. By accurately completing this form, you can facilitate the management of medical information with transparency and security.
Follow the steps to effectively complete the Adultproxy form.
- Press the ‘Get Form’ button to obtain the Adultproxy form and open it in your preferred document editor.
- Fill out the 'Your Information' section clearly. Enter your name (last, first, middle initial), sex, email, street address, phone number, date of birth, city, state, primary physician, and zip code.
- Complete the 'Patient’s Information' section with the required details about the patient whose MyCare record you want to access. This includes their name, date of birth, sex, email, street address, phone number, city, state, primary physician, and zip code.
- Read the 'MyCare Terms and Agreement' section carefully. Ensure you understand the implications of designating a proxy and the responsibilities associated with managing the MyCare account.
- Provide your signature in the 'Your (Proxy) Signature' section to acknowledge consent. Indicate your relationship to the patient and the date.
- Ensure the patient signs the form in the 'Signature of Patient (or authorized person)' section, along with indicating their relationship to the patient and the date.
- Complete the 'Authorization for Release of Medical Information' section, including the patient's name, date of birth, and the designated proxy's name. Ensure the patient signs and dates this section.
- Once all sections are filled out and signed, review the form for completeness and accuracy. You can then save changes, download, print, or share the completed form as needed.
Complete your documents online today and streamline your access to medical information.
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