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Pt. Name:___ Address:___ ___ City State Request FOR CHART PROXY ACCESS DOB: ___SEX: ___Terms and Conditions Thank you for your interest in UT Southwestern Chart, our secure online health management
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MyChart-npet1030epichostedcommychartpocmychart - access authorization is a system used to manage patient access to their electronic health records and personal health information securely.
Patients wishing to access their electronic health records through the MyChart system are required to file the mychart-npet1030epichostedcommychartpocmychart - access authorization.
To fill out the mychart-npet1030epichostedcommychartpocmychart - access authorization, complete the provided form with your personal details, check the necessary consent boxes, and submit it to your healthcare provider.
The purpose of the mychart-npet1030epichostedcommychartpocmychart - access authorization is to grant patients the ability to access and manage their health information across various healthcare services securely.
The following information must be reported: patient name, date of birth, contact information, healthcare provider details, and any specific access permissions requested.
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