Get Request For Proxy Access To An Adult's Mychart

The Request For Proxy Access To An Adult's MyChart is an essential document that allows designated individuals to access a patient's medical information securely. This guide will provide clear, step-by-step instructions to help you fill out this form accurately and effectively.

Follow the steps to complete your Request For Proxy Access form.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. In the Request for Access section, provide your personal information. Fill in your name (last, first, middle initial), the last four digits of your Social Security number, date of birth, address (street, city, state, zip code), email address, and telephone number.
3. Indicate your relationship to the patient by checking the appropriate box. Options include Legal Guardian, Surrogate or Durable Power of Attorney for Healthcare, Statutory Proxy, or Other. If selecting 'Other', provide a brief explanation of your relationship.
4. Ensure that you have the MyChart Proxy Authorization form signed by the patient if they are competent to give consent.
5. Move to the Patient's Information section and complete it with the required details about the adult patient. Include their name (last, first, middle initial), last four digits of their Social Security number, date of birth, address (street, city, state, zip code), and telephone number.
6. Read the requirements and procedures for accessing the patient's medical records and check the agreement box indicating your understanding.
7. Sign the form by providing your signature as the individual requesting access, along with the date and your printed name as the Proxy.
8. Finally, review the completed form for accuracy, save your changes, download a copy for your records, and print or share the form as needed.

Complete your Request For Proxy Access form online today to ensure timely and secure access to important medical information.