Adult Proxy Form

Request for Proxy Access to Adult Patient's My Chart Record

This Form may be used by an individual who helps manage the medical care of another adult (a "Proxy") to request access to the MyChart record of that adult (the "Patient"). The Patient and the Proxy must both complete and sign this Form. Please note that the Patient's chart will be accessed through the Proxy's MyChart record. Completing this Form will establish a MyChart record for the Proxy and for the Patient, if the Patient has not already established a MyChart record. Both the Patient and Proxy must provide complete and accurate information. Incomplete forms may result in delays or denial of access.

Proxy's Information

Last Name:

First Name:

Middle Initial:

Social Security Number (last 4 digits only):

Date of Birth:

Phone Number:

Email Address:

Street Address:

City:

State:

Zipcode:

Patient's Information

Last Name:

First Name:

Middle Initial:

Social Security Number (last 4 digits only):

Date of Birth:

Phone Number:

Email Address:

Street Address:

City:

State:

Zipcode:

MyChart Terms and Agreement By signing this Form, I acknowledge and understand that:

The Patient's health information is protected under federal and state laws. By completing this Form, the Patient is authorizing disclosure of selected health information to the Proxy.

MyChart is a secure online source of confidential medical information. I agree that it is my responsibility to select a confidential password, to maintain my password in a secure manner, and to change my password if I believe it may have been compromised in any way. If I share my MyChart ID and password with another person, that person may be able to view either the Proxy's or the Patient's health information.

MyChart contains selected, limited medical information from the medical record, and MyChart does not reflect the complete contents of the medical record.

My activities within MyChart are trackable, and the entries I make may become part of the medical record.

Access to MyChart is provided by Shepherd Center as a convenience and access is meant to help individuals manage the Patient's healthcare. Shepherd Center has the right to deactivate access to MyChart at any time for any reason.

Use of MyChart is voluntary, and I am not required to use MyChart or to designate a MyChart proxy. However, I also understand that if this Form is not completed, Shepherd Center will not provide proxy access to MyChart.

Once information is disclosed, it may be re-disclosed and may no longer be protected by federal or state privacy laws.

Shepherd Center does not condition health care treatment, payment, or other services on whether this Form is completed.

The Patient may revoke the Proxy's access at any time by providing a written request for revocation to Shepherd Center. This revocation will not affect any disclosures that were made before the revocation request.

The Proxy may have access to the Patient's MyChart until the Patient revokes the access.

Proxy

I acknowledge that I have read and understand this Form and I agree to its terms.

Patient

I acknowledge that I have read and understand this Form. I agree to its terms and choose to designate the person named above as my Proxy, thereby allowing them access to my MyChart medical record.

Contact Information