Follow the steps to accurately complete the UAMS MyChart proxy request form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with your information. In this section, clearly print your name (last, first, middle initial), Social Security number, date of birth, street address, phone number, email address, city, state, and zip code. Ensure all fields are filled accurately.
3. Proceed to the patient’s information. This section should contain the same information as yours, but for the patient whose MyChart record you intend to access. Ensure you complete all required fields.
4. Read the Proxy MyChart terms and agreement carefully. Ensure you understand each point, as it outlines your responsibilities and the conditions under which MyChart access is granted.
5. Sign the form in the designated area where it indicates 'Your (Proxy) Signature (Required)'. Input your relationship to the patient and the date of signing.
6. If you are not the patient, ensure that the patient adds their name, Social Security number, date of birth, and signature for authorization. If someone else is signing for the patient, include the authority documentation.
7. Save your changes. Once completed, review the form for any errors and finalize it. You can then download, print, or share the completed form as necessary.

Start completing your UAMS MyChart proxy request form online today!