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Get Sanford Adult/Teen Proxy Form 2018

My Sanford Chart Adult/Teen Proxy Please fill out this form to give someone else consent to see your My Sanford Chart patient record. I may take away consent through My Sanford Chart or by mail to the address above. I understand that if I take away consent my proxy s access to my health record will end. Mail this form to Sanford Business Center Route 5228 2200 E. Benson Road Sioux Falls SD 57104 About the Patient All sections required please print clearly Name last first middle initial Date of Birth Last 4 numbers of Social Security Number Email Phone Number About the Proxy All sections required please print clearly Complete for the person getting access to the Patient s My Sanford Chart record Street Address City State Zip I ask that my Proxy whose name is above have access to my complete patient record including My I also give consent for my Proxy to do these things for me See make and check-in for appointments See and send messages to my health care team Update my name address personal data and payment or insurance details See who has accessed my medical record through My Sanford Chart Get copies of any part of my medical record. This person is called your Proxy. Bring it with you to your next visit or mail it to the address shown below. If you choose to mail this form it must be notarized first. A notary is a person with a special license to watch you sign legal forms. Have my medical record sent to any third party. I understand and agree My Proxy may have access to behavioral health and alcohol or drug treatment records. Records given to my Proxy may be given to others and no longer protected* Naming a Proxy is my choice and not required* I do not have to give this consent. I will receive care even if I do not sign this consent. I understand that if I do not sign this access will not be given to my proxy. If I am over 18 this consent expires 5 years from the date of my signing. If I am a minor it will expire when I turn 18. I understand this will not prevent the release of data already given* I have read and understand this form* / Signature of Patient or authorized person Required Relationship to Patient Date Notary if mailed or patient not present 019038-00024 Rev* 3/18. This person is called your Proxy. Bring it with you to your next visit or mail it to the address shown below. If you choose to mail this form it must be notarized first. A notary is a person with a special license to watch you sign legal forms. Have my medical record sent to any third party. I understand and agree My Proxy may have access to behavioral health and alcohol or drug treatment records. Records given to my Proxy may be given to others and no longer protected* Naming a Proxy is my choice and not required* I do not have to give this consent. Records given to my Proxy may be given to others and no longer protected* Naming a Proxy is my choice and not required* I do not have to give this consent. I will receive care even if I do not sign this consent. I understand that if I do not sign this access will not be given to my proxy. .

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