Website Adult Proxy Access to an Adult’s MyChart Record

This form is an authorization that will permit One Community Health to release your medical information to your designated adult proxy. This form should be completed by the patient who is authorizing another adult to access medical information in his or her MyChart electronic record. This form must include the name and information of the patient and the individual who the patient is authorizing to access their MyChart record as a proxy.

Patient Name*

First NameMiddle NameLast NameSuffix

Patient Date of Birth*

Date

Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

I am requesting that (type printed name of proxy below):*

First NameLast Name

whose birth date is (type birth date of proxy below):

Date

whose address is (type printed address of proxy below):*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

whose phone number is (type phone number of proxy below):*

Please enter a valid phone number.

whose email address is (type email address of proxy below):

example@example.com

be allowed to have access to my health information that is available in my MyChart electronic record. This person is my designated MyChart proxy. I authorize One Community Health to release the health information contained in my electronic MyChart record to my proxy. I understand that the medical information in MyChart is obtained from my electronic medical record and may include information from facilities listed in One Community Health Notice of Privacy Practices. I understand that MyChart contains a portion of my medical record and that MyChart does not reflect the complete contents of the medical record. Information in MyChart may include pregnancy, STD treatment, reproductive health care, alcohol and/or substance abuse treatment, genetic testing, mental health or HIV related information.

I authorize release of my health information only through my electronic MyChart record. This form does not authorize release of my medical record to my designated proxy by other methods or in other ways. I understand that once information has been disclosed, it could be re-disclosed by the proxy, and the disclosed information may not be protected by federal privacy protections.

Participation in MyChart and designating a MyChart proxy is completely voluntary. Access to my MyChart electronic record is solely at my request. I understand that I am not required to designate a MyChart proxy and I am not required to provide MyChart access authorization to any other person. I also understand that One Community Health does not condition any of my health care treatment, payment or other services on whether I provide this authorization. However, I also understand that if I do not provide this authorization, One Community Health is not permitted to provide access to my MyChart record to my designated proxy.

This authorization will expire only when I revoke my permission for my proxy to access my information through MyChart. I understand that I also may revoke this authorization at any time by providing a written request for revocation to One Community Health. I understand that if I revoke this authorization, my designated proxy’s access to my MyChart record will end. I also understand my revocation will not affect any disclosures that were made prior to processing the revocation request and that any redisclosures made by the proxy may no longer by covered by federal privacy protections. I have been provided a copy of this authorization.

Printed Name *

First NameLast Name

Date Signed*

Date

Signature*

If a personal other than the patient signs this form, indicate their legal authority to sign for patient (e.g., legal guardian) and attach documentation:

NOTE: Authorization will only expire when I revoke my permission for my proxy to have access to my information through MyChart, or when One Community Health is notified of my death. I may deactivate the access of the adult proxy specified above by providing a written request to One Community Health.