Get Adult Proxy Authorization

The Adult Proxy Authorization form allows an individual to request access to another adult's My Healthy Connection medical record. This guide provides a clear and supportive set of instructions for completing the form online to ensure a smooth and accurate submission.

Follow the steps to complete the Adult Proxy Authorization form online.

1. Click ‘Get Form’ button to obtain the authorization form and open it in the editor.
2. Fill in your personal information in the 'Your Information' section. This includes your full name, phone number, email address, date of birth, social security number, street address, city, state, and zip code. Ensure that all sections are completed clearly.
3. Proceed to the 'Patient’s Information' section. Here, provide the details of the patient whose My Healthy Connection record you are requesting access to. Include the patient’s full name, date of birth, email address, street address, city, state, zip code, and phone number.
4. Read and understand the My Healthy Connection Terms and Agreement thoroughly. This confirms your awareness of the privacy and security aspects related to accessing the medical records.
5. Sign the authorization form in the designated area to acknowledge that you have read and understand the agreement. Additionally, indicate your relationship to the patient.
6. Finally, the patient must sign the authorization form as well, confirming their consent for you to act as their My Healthy Connection proxy. They should also indicate their relationship to you.
7. Once all sections are completed and signed, save your changes. You may then choose to download and print the form or share it electronically. Ensure that you return the completed form to Riverside Medical Clinic as instructed.

Complete your Adult Proxy Authorization form online today to ensure easy access to medical records.