Get Sanford My Chart

Filling out the Sanford My Chart Adult/Teen Proxy Form ensures that individuals can request access to the My Sanford Chart account of another adult or teen whose medical care they help manage. This guide provides step-by-step instructions to assist users in completing the form accurately and efficiently.

Follow the steps to complete the Sanford My Chart Adult/Teen Proxy Form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by completing the 'Your Information' section. Provide your name (last, first, middle initial), date of birth, last four digits of your Social Security number, email address, street address, city, state, zip code, phone number, and primary physician's name. Ensure all sections are printed clearly.
3. Next, fill out the 'Patient’s Information' section with the required details of the patient whose account you are requesting access to. Include their name (last, first, middle initial), last four digits of their Social Security number, phone number, date of birth, email, and primary physician's name.
4. Read through the 'My Sanford Chart Terms and Agreement' section carefully. Acknowledge your understanding by signing in the designated area. Indicate your relationship to the patient and the date.
5. Complete page two of the form, which serves as the 'Adult/Teen Proxy Authorization for Release of Medical Information'. Fill in the patient's name, last four digits of their Social Security number, and date of birth. Designate the proxy's name and authorize the release of information.
6. Sign the authorization, ensuring you understand that the access granted to the proxy is voluntary and can be revoked at any time.
7. Once you have filled out all sections fully, you can save changes, download the completed form, print it, or share it as needed for submission.

Complete your Sanford My Chart forms online today for efficient healthcare management.