Get the free myChart Proxy Form

For patients between the ages of 1217 To sign up for access to your INCH Chart record, please complete this form in its entirety. Please note that your parent or guardian will need to sign the form

How to fill out mychart proxy form

How to fill out mychart proxy form

1. Obtain a MyChart proxy form from the healthcare provider.
2. Fill in the required information, including your name, date of birth, contact information, and relationship to the patient.
3. Provide the patient's name and date of birth on the form.
4. Sign and date the form to authorize access to the patient's medical information.
5. Submit the completed form to the healthcare provider for processing.

Who needs mychart proxy form?

1. Individuals who are authorized to make medical decisions for a patient
2. Parents or legal guardians of minor children
3. Caregivers or family members providing support for a patient

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What is mychart proxy form?

Mychart proxy form is a document that allows a designated individual to access and manage another person's medical information through Mychart.

Who is required to file mychart proxy form?

Anyone who wants a designated individual to access their medical information through Mychart is required to file a mychart proxy form.

How to fill out mychart proxy form?

To fill out a mychart proxy form, you need to provide your basic information, designate the individual who will have proxy access, and sign the form.

What is the purpose of mychart proxy form?

The purpose of mychart proxy form is to grant a designated individual access to another person's medical information through Mychart for easier management and coordination of care.

What information must be reported on mychart proxy form?

The mychart proxy form must include basic information about the individual granting proxy access and the designated individual, along with signatures from both parties.