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My Health Portal Proxy Access Request and Authorization Form For help with this form, please contact the Patient Portal Help Desk at 83077835941. Patient Information: Patient Name: ___ Date of Birth:

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How to fill out my health portal proxy

01

Sign in to your health portal account

02

Locate the section for proxy access

03

Enter the required information for your designated proxy

04

Review and confirm the proxy access permissions

05

Submit the request for proxy access

Who needs my health portal proxy?

01

Individuals who are unable to access or manage their health portal account on their own

02

Patients who wish to designate a trusted individual to assist with managing their health information

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What is my health portal proxy?

Your health portal proxy is a designated individual who can access your health information and make decisions on your behalf.

Who is required to file my health portal proxy?

You are required to file your health portal proxy, usually with your healthcare provider or insurance company.

How to fill out my health portal proxy?

You can fill out your health portal proxy by completing the necessary forms provided by your healthcare provider or insurance company.

What is the purpose of my health portal proxy?

The purpose of your health portal proxy is to ensure that someone can access your health information and make decisions for you if you are unable to do so.

What information must be reported on my health portal proxy?

Your health portal proxy must include the name of the designated individual, their contact information, and any limitations or restrictions on their authority.

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