Get Your Information: (for Your Mychart Sign-up And Proxy Access ...

Completing the Your Information form for MyChart sign-up and proxy access is an important step toward managing your healthcare records. This guide will walk you through each section, ensuring you understand the requirements and can fill out the form accurately.

Follow the steps to complete your form successfully.

1. Press the ‘Get Form’ button to access the form and open it in your preferred document editor.
2. Begin by entering the name of the proxy in the format of last name, first name, and middle initial in the designated field.
3. Fill in the street address of the proxy followed by their date of birth (DOB) formatted as month/day/year.
4. Add the city, state, and zip code of the proxy's residence in the appropriate fields.
5. Enter the proxy's phone number, ensuring it is accurate for future communications.
6. Select the type of proxy access you are requesting by checking the corresponding box. This includes options for adult-adult access or adult-child access.
7. If requesting access as a legal guardian, print the title of the legal document granting guardianship and fill it in as required.
8. For adult patient information, provide the required details including name, date of birth, street address, city, state, zip code, and primary clinic, making sure to print clearly.
9. For minor children, complete the child's information section including name and date of birth, and primary clinic. If there are more than four children, request an additional form.
10. Review the MyChart terms and agreement section, and ensure you understand the responsibilities tied to password confidentiality and email address accuracy.
11. In the signature fields, sign where indicated, including the relationship to the patient, and ensure dates are filled in accurately.
12. Finally, save changes, and consider downloading, printing, or sharing the completed form as necessary. Submit the form to Meriter Hospital, Health Information Management Department, as specified.

Complete your MyChart sign-up and proxy access form online today to manage your healthcare effectively.