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For Internal Use: MR# Acct#/Encounter# ROI# Revoke Proxy Access to Patient Portal Authorization * This form must be completed in order to revoke proxy access to your patient portal * Patient Name:

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How to fill out my health portal proxy

01

Log in to your health portal account using your credentials.

02

Navigate to the proxy section of the portal.

03

Click on the 'Add Proxy' or similar button.

04

Enter the necessary details of the person you want to add as your proxy, such as their name, contact information, and relationship to you.

05

Review and confirm the information you have entered.

06

Submit the proxy request and wait for it to be reviewed and approved by the health portal administrator.

07

Once the proxy request is approved, the person you added as your proxy will be able to access and manage certain aspects of your health information on your behalf.

Who needs my health portal proxy?

01

My health portal proxy can be useful for anyone who wants to grant access to their health information and allow someone else to manage their healthcare needs. This could include individuals who are unable to navigate the health portal themselves, such as elderly or disabled individuals, or those who simply prefer to have a trusted person assist them with their healthcare management. Additionally, family members or caregivers may also need the health portal proxy to access and monitor the health information of their loved ones.

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What is my health portal proxy?

Your health portal proxy is a document that designates a person to make health care decisions on your behalf if you are unable to do so.

Who is required to file my health portal proxy?

Individuals who are 18 years old and above are required to file a health portal proxy.

How to fill out my health portal proxy?

You can fill out your health portal proxy by providing personal information, specifying your proxy decision maker, and signing the document.

What is the purpose of my health portal proxy?

The purpose of your health portal proxy is to ensure that your health care preferences are respected in the event that you are unable to communicate them yourself.

What information must be reported on my health portal proxy?

Your health portal proxy must include personal information, contact details of your proxy decision maker, and specific health care directives.

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