Get Nc Cone Health Mr99119 2020-2025

The NC Cone Health MR99119 form is designed to authorize an adult to access another individual's MyChart medical record. This guide provides a step-by-step process to accurately complete the form online, ensuring both the patient and proxy understand the necessary sections and fields.

Follow the steps to complete the NC Cone Health MR99119 form online.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Complete the section labeled 'Proxy’s name' by entering the full name of the authorized adult who will access the MyChart record.
3. In the same section, fill in the 'DOB' (date of birth) of the proxy to verify their identity.
4. Enter the 'Address' of the proxy, ensuring all details are clear and accurate.
5. Provide the last four digits of the proxy's Social Security Number (SSN) for identification purposes.
6. Fill in the 'City/State/Zip' where the proxy resides and ensure the information is correctly formatted.
7. List a valid 'Telephone #' where the proxy can be reached.
8. Include the proxy's 'email address' as it is required for notifications.
9. Indicate whether the proxy has ever been a patient at Cone Health by selecting 'Yes' or 'No'.
10. The proxy must read the terms of the MyChart access form. Once understood, they should sign and date the form.
11. In the 'Patient Information' section, repeat the steps above by filling in the patient’s details including their name, DOB, address, last four digits of SSN, city/state/zip, phone number, and email address.
12. The patient or authorized representative must sign and date the form to confirm their understanding and agreement.
13. If applicable, complete the 'Physician Certification' section by having the physician sign and date, certifying the patient’s condition.
14. Review all sections for completeness and accuracy before submitting the form.
15. Finally, users can save changes, download a copy, print the document, or share it as needed.

Complete your NC Cone Health MR99119 form online today to ensure access to important medical information.