Adolescent And Adolescent And Adult Proxy Form

Adolescent And Adult Proxy Form
Access to an Adolescent’s (age 12-17)
17) or Adult’s MyChart Record
To request access to the MyChart record of a
an adolescent age 12-17 or an adult whose medical care you help manage,
please complete this form. The patient’s MyC
MyChart record will be accessed through your MyChart record. If you do not have
access to MyChart an activation letter will be sent to your home address. You will then need to activate
act
your account to
view the adolescent or adult’s MyChart record. Once an adolescent reaches age 18, this form will expire and a proxy
will no longer have access to the child’s MyChart record. This form may be completed again for Adult Proxy at that
t
time.
Return forms to McFarland Clinic MyChart Services, PO Box 3014 Ames, IA 50010, or fax to (515) 956-4189.
Proxy Information (All sections required – please print clearly)
This section should be completed by the individual seeking access to another person’s MyChart record.
Name (last, first, middle initial)
Date of Birth
Last 4 digits of SSN
Street Address
Email
City
State
Zip
Phone Number
Patient’s Information (All sections required – please print clearly)
Complete this section with information about the patient whose MyChart record you’re requesting access to.
Name (last, first, middle initial)
Date of Birth
Last 4 digits of SSN
Street Address
Email
City
State
Zip
Phone Number
Patient hereby agrees to the following:
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•
•
•
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I authorize release of any information (including any protected health information) contained in my MyChart
medical record maintained by McFarland Clinic
Clinic, P.C. (“McFarland Clinic”) to the person named above as my
MyChart proxy.
I understand that my information in MyChart is obtained from my electronic medical record and may include
information regarding mental health/depression, substance abuse (alcohol
alcohol or drug)
drug and infectious
disease, including AIDS/HIV from all facilities in the McFarland Clinic Notice of Privacy Practices. IMPORTANT:
PATIENT MUST INITIAL THIS SECTION:____________
I authorize release of this information only through my MyChart record. This form does not authorize release of
my medical record to my designated pr
proxy by other methods or in other forms.
I understand that once information has been disclosed, it potentially may be re
re-disclosed
disclosed by the proxy and the
disclosed information may not be covered by federal privacy protections.
I understand that access to MyChart
art is provided by McFarland Clinic and Mary Greeley Medical Center as a
convenience to its patients and McFarland Clinic or Mary Greeley Medical Center has the right to deactivate
access to MyChart at any time for any reason. I understand that use of MyCh
MyChart
art is voluntary and I am not required
to use MyChart or to authorize a MyChart proxy.
I may revoke this authorization at any time online pursuant to instructions at www.mcfarlandclinic.com or by
providing a written request for revocation to my primary clinic. I understand that iiff I revoke this authorization, my
designated proxy’s access to MyChart record will be ended. I also understand my revocation will not affect any
disclosures that were made prior to pr
processing the revocation request.
By signing below, I acknowledge that I have read and understand this MyChart Adolescent and Adult Proxy Form
and I agree to its terms.
Signature of Patient or Authorized person (Required)
Proxy Signature (Required)
Date
Relationship to Patient
Date
MyChart is a registere
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