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*9004281* Affix Patient Label Name: Date of Birth: Allowing Another Person to Look at Bronson Chart Record (Ages 12 and up) Proxy Information (Please print clearly and fill out all parts) Name (last,

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How to fill out mychart proxy form

How to fill out mychart proxy form:

01

Obtain the mychart proxy form: The first step in filling out the mychart proxy form is to obtain the form itself. This can usually be done by visiting the website of your healthcare provider or contacting their office directly.

02

Read the instructions: Before starting to fill out the form, it is important to read the instructions carefully. The instructions will provide you with important information about who can act as a proxy, what actions they can take on your behalf, and any other specific requirements.

03

Provide personal information: The next step is to provide your personal information on the form. This may include your name, date of birth, address, contact information, and any other relevant details requested.

04

Identify your proxy: In the mychart proxy form, there will be a section where you need to identify the person you are appointing as your proxy. This may include their name, relationship to you, and their contact information.

05

Specify proxy privileges: Depending on the mychart proxy form, there may be different levels of proxy privileges that you can assign. Specify the extent to which your proxy can access your medical records and make decisions on your behalf. Make sure to check all the relevant boxes and provide any necessary additional information.

06

Sign and date the form: Once you have completed filling out the mychart proxy form, it is important to sign and date the document. This signature indicates that you understand and agree to the terms and conditions outlined in the form.

Who needs mychart proxy form:

01

Patients with limited capacity: The mychart proxy form is designed for individuals who have limited capacity to access or manage their own medical records. This could include individuals with cognitive impairments, serious illnesses, or individuals who are temporarily unable to make decisions for themselves.

02

Guardians or caregivers: The mychart proxy form is often used by guardians or caregivers who are responsible for managing the healthcare needs of another individual. This form allows them to access medical records and make decisions on behalf of the patient.

03

Family members or close friends: In some cases, individuals may choose to appoint a family member or close friend as their mychart proxy. This can be helpful in situations where the patient wants someone they trust to have access to their medical information and be able to make decisions on their behalf.

It is important to note that the specific requirements for who needs a mychart proxy form may vary depending on the healthcare provider or jurisdiction. It is advisable to consult with your healthcare provider or legal counsel for further guidance.

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