Get My Clinicchart Proxy Access Bformb - Avera - Avera

This guide provides clear instructions for completing the My ClinicChart Proxy Access BFormb. Whether you are a proxy assisting someone with medical needs or the patient themselves, understanding how to fill out this form is essential for gaining access to important medical records.

Follow the steps to complete your Proxy Access Form online.

1. Press the 'Get Form' button to obtain the form and access it through your preferred editing tool.
2. Begin with the 'Patient Information' section. Fill in all required fields, including the patient's name (last, first, middle), date of birth, age, last four digits of their social security number, and contact details such as phone number, street address, city, state, and zip code.
3. Proceed to 'Proxy Information.' Here, complete the required fields, providing your name, phone number, street address, city, state, zip code, and email address.
4. In the 'Authority of Proxy' section, select the appropriate statements that pertain to your relationship to the patient. This will help establish your right to access their medical records.
5. Review the 'My Clinic Chart Terms and Agreement' section. Carefully read each bullet point as it outlines your responsibilities and the nature of the access granted.
6. Complete the 'Proxy' and 'Patient' acknowledgment sections by providing your signature and relationship to the patient, along with the current date. If the patient is a minor or if you have legal authority, the patient's signature may not be necessary.
7. Finally, submit the completed form by returning it to the Family Medicine Clinic via mail, fax, or email as provided in the instructions.

Begin filling out your My ClinicChart Proxy Access Form online today!