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MyChartProxy Revocation Form
Fill out this form to remove someone (called a revocation) that currently has access to your Chart record.
This person is called your Proxy. This form may be completed
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How to fill out mychart proxy revocation form
How to fill out mychart proxy revocation form
01
Download the mychart proxy revocation form from the official website.
02
Fill out your personal information, including your name, address, date of birth, and contact information.
03
Indicate the name of the person you are revoking proxy access for.
04
Sign and date the form to confirm the revocation of proxy access.
05
Submit the completed form by mail or in person to the appropriate healthcare provider.
Who needs mychart proxy revocation form?
01
Patients who previously granted proxy access to another individual through mychart may need to fill out the mychart proxy revocation form to revoke that access.
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What is mychart proxy revocation form?
The MyChart proxy revocation form is a document used to officially revoke or cancel the access privileges granted to a proxy user for viewing or managing a patient's healthcare information on the MyChart platform.
Who is required to file mychart proxy revocation form?
The form must be filed by the patient who wishes to revoke access previously granted to a proxy user, typically a family member or caretaker.
How to fill out mychart proxy revocation form?
To fill out the MyChart proxy revocation form, a patient must provide identifying information, such as their name, date of birth, and details about the proxy user they wish to revoke access from, as well as the date of submission and their signature.
What is the purpose of mychart proxy revocation form?
The purpose of the MyChart proxy revocation form is to legally remove a proxy's access to the patient's medical information and ensure that the patient maintains control over who can view or manage their health records.
What information must be reported on mychart proxy revocation form?
The form must include the patient's personal information, such as their full name, date of birth, the name of the revoked proxy, the reason for revocation (if applicable), and a confirmation of the patient's signature.
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