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  • Adult Proxy Access Request Form.indd - Healthpartners

Get Adult Proxy Access Request Form.indd - Healthpartners

Signature of Patient Date Mail completed and signed form to Release of Information Services MS 25510C PO Box 1490 Mpls MN 55440 For internal use only Authorization to share information Request to release records. Release of Information Services MS 25510C PO Box 1490 Minneapolis MN 55440-1490 Online Patient Services System Adult Proxy Access Request Patients Full Name Daytime phone number Address Gender M or F City Date of Birth State Zip Medical .

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This Adult Proxy Request Form (this “Form”) is to be completed by an adult patient (the “Patient”, “you” or “your”) who is 18 or over and can make (and understand) the Patient's healthcare decisions and wants to give another person (a “Proxy”) the right to access Patient's information available through the MyChart ...

Proxy access allows parents, legal guardians or caregivers to access a patient's health. information on the patient portal. Proxy access is an available option for adult patients. (18 years) and pediatric patients (newborn – 12 years of age).

This form should be completed by a parent or permanent legal guardian (“Proxy”) who wants to request access to another patient's (or your child's) My CS-Link Record. The Proxy will need to show a photo ID and/or relevant legal or court documents asserting their right to make such request.

Some companies usually give a proxy form along with the Notice of Meeting for their members to fill out the form if they want to appoint a proxy to vote on their behalf. In this document, the member's name and address will be entered, as well as the name of the company and the full name of the proxy.

What is proxy access? Proxy access allows you to securely communicate with the patient's physician's office on behalf of a family member or person under your care.

For Proxy access to an adult account The Patient granting access must login to their MyChart account on your computer at mychart.mhs.net or on the mobile app. Select Friends and family access Click on Invite someone. Fill out all fields to send someone an invitation to receive proxy access to your account.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232