Loading
Get University Of Virginia Health System Form 110163 2015-2025
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the University Of Virginia Health System Form 110163 online
This guide provides a detailed, user-friendly approach to completing the University Of Virginia Health System Form 110163 online. Follow the steps below to ensure that you accurately fill out the form to authorize proxy access to your MyChart account.
Follow the steps to successfully complete the form.
- Click the ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by filling in the patient's name and medical record number in the designated fields. If a label is not available, you will need to write this information directly.
- Enter the patient’s date of birth and select the gender by checking the appropriate box. Ensure that this information is accurate to avoid any issues.
- Provide the patient’s address and email address. If the patient does not have an email, select the option indicating 'None'.
- Fill in the details of the adult seeking proxy access, including their name, phone number, date of birth, and email address. If they are a UVA patient, include their medical record number.
- Specify the relationship of the adult proxy to the patient by checking the appropriate box (e.g., spouse, son/daughter, other) and provide additional information if necessary.
- Both the patient and the adult proxy must sign and date the authorization sections, acknowledging that they understand the terms and conditions related to MyChart access.
- Complete the validation section by having necessary personnel validate proxy identification. This may involve staff signatures and roles.
- Once the entire form is filled out, review all information for accuracy. Save changes if applicable, and proceed to download, print, or share the completed form.
Complete your forms online today to ensure a smooth process.
University health system emails generally follow a consistent format across various institutions. They typically use the first initial and last name of the staff or faculty member, followed by the domain of the university. If you're looking for contact details or guidance on the University Of Virginia Health System Form 110163, using this email structure can facilitate your inquiries.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.