Follow the steps to complete the Mykelseyonline form.

1. Press the ‘Get Form’ button to access the form and open it in your editor.
2. Begin by completing the 'Your Information' section. Provide your full name, date of birth, email address, street address, city, state, zip code, and phone number. Ensure all information is printed clearly.
3. Next, fill out the 'Patient’s Information' section with the details of the patient whose Mykelseyonline account you are requesting access to. This includes their full name and date of birth as well as their address, city, state, and zip code.
4. In the provided statement, write the name of the individual you are designating as your proxy. This person will receive access to the health information in your MyKelseyOnline account.
5. Review the authorization statement thoroughly, as it confirms your understanding of the rights and specifics regarding the release of your medical information.
6. Sign and date the form where indicated. If you are signing on behalf of the patient, make sure to indicate your authority to sign for them and attach any necessary documentation.
7. Your proxy should also sign the form if required. After completing the form, save your changes, then download, print, or share the completed document as necessary.

Complete your documents online today to ensure your medical information is accessible to your designated proxy.