Get Mychart Proxy Consent Form - Healtheast Care System

The MyChart Proxy Consent Form allows patients or their guardians to grant access to another individual for viewing medical information. This guide will walk you through the process of filling out this form online, ensuring a smooth and efficient completion.

Follow the steps to successfully complete the MyChart Proxy Consent Form.

1. Press the ‘Get Form’ button to obtain the MyChart Proxy Consent Form and open it in your chosen editor.
2. Complete the 'Patient Information' section by entering the patient's name, date of birth, phone number, address, email, and primary clinic/provider. Be sure to fill in all the fields clearly.
3. In the 'Access to be provided to' section, fill out the information of the individual or guardian who will be granted access to the patient’s or minor child’s MyChart records, including their name, date of birth, phone number, address, email, and relationship to the patient.
4. If the patient is a minor aged 12-17, the patient must sign to grant consent allowing their parent or legal guardian full access to their medical information. Ensure this section is completed and dated.
5. Review the MyChart Terms and Conditions for Granting/Receiving Proxy Access. Read each point thoroughly to understand the implications of granting access.
6. The patient (age 12 and older) and the parent/legal guardian must provide their signatures and dates in the designated areas, acknowledging agreement to the terms.
7. After reviewing and signing the form, save the changes. You may also download the completed form, print it, or share it as required.

Complete the MyChart Proxy Consent Form online today for seamless access to important health information.