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Te both pages of this form. The patient must sign this form and provide authorization on page 2 via the Adult OSF myHealth Proxy Authorization for Access to Medical Information form. The patient s account will be accessed through your (the proxy s) OSF myHealth account. Completion of this form is required before we can establish an OSF myHealth account for you and access to the patient s information. Return forms to your OSF representative. Please enter Patient s Information below.

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