Get the free Mychart Proxy Authorization Form

This form authorizes a proxy to access a patient\'s personal health information through MyChart, which is managed by Gundersen Health System and its Community Connect Partners. It outlines the patient\'s personal information, the proxy\'s details, and the scope of access granted, including medical records, appointment requests, and prescription renewals. The patient retains the right to revoke this authorization at any time.

How to fill out mychart proxy authorization form

How to fill out mychart proxy authorization form

1. Download the MyChart Proxy Authorization Form from the MyChart website.
2. Fill in your personal information at the top of the form, including your name, address, and date of birth.
3. Provide the name and contact information of the proxy (the person you are allowing access to your medical information).
4. Indicate the level of access you want to grant the proxy (full access, limited access, etc.).
5. Sign and date the form to authorize the proxy access.
6. Submit the completed form to your healthcare provider's office as instructed (either in person or via email/fax).

Who needs mychart proxy authorization form?

1. Individuals who wish to grant access to their MyChart account to a family member or caregiver for managing health information and appointments.

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What is mychart proxy authorization form?

The MyChart proxy authorization form is a document that allows an individual to grant permission to another person to access their MyChart account, which includes personal medical information and health records.

Who is required to file mychart proxy authorization form?

Individuals who want to allow someone else to access their medical records through MyChart need to file the proxy authorization form.

How to fill out mychart proxy authorization form?

To fill out the MyChart proxy authorization form, you need to provide personal information, designate the proxy, specify the type of access given, and sign the form to confirm your wishes.

What is the purpose of mychart proxy authorization form?

The purpose of the MyChart proxy authorization form is to legally grant access to a third party to view and manage your health information in MyChart.

What information must be reported on mychart proxy authorization form?

The form typically requires personal details such as your name and contact information, the proxy's name and contact information, and the scope of access being granted.