MyChart Teen Proxy Form

MyChart Teen Proxy Form Parental Access to the Online Medical Record of a Patient 15 to 17 Years Old Once a child reaches the age of 15 a parent will only have partial access to their child’s MyChart record. To request full proxy access to the MyChart record of your teen age child, please complete this form. The patient must sign this form and provide authorization for release of medical information in MyChart on the “Teen Proxy Authorization Form.” Please note that the patient’s chart will be accessed through your (the proxy’s) MyChart record. Completing this form will establish a MyChart record for you and for the patient. Return forms to your Primary Care Physician’s Office. Parent Information (All sections required – please print clearly.)
This section should be completed by the parent requesting access to their teenage child’s MyChart record.
Name (last, first, middle initial):____________________________________ Date of Birth:____________________
Social Security Number:____________________________ Email:___________________________________
Street Address: __________________________ City: __________________ State: _______ Zip:__________
Phone Number: _______________________________Primary Clinic: ________________________________
Patient’s
Information (All sections required – please print clearly.)
Complete this section with information about the patient whose MyChart record you’re requesting to access.
Name (last, first, middle initial):____________________________________ Date of Birth:____________________
Social Security Number:____________________________ Email:___________________________________
Street Address: __________________________ City: __________________ State: _______ Zip:__________
Phone Number: _______________________________Primary Clinic: ________________________________
MyChart Terms and Agreement I have read and understand the requirements and procedures for accessing my medical record information online as provided in the MyChart Terms and Conditions which can be obtained at your physician’s office or online at https://mychart.casso.us.com. I agree to allow my birth parent/legal guardian, named above, online access to my medical information currently available and that may become available as a result of future medical care. I understand I may revoke this access at any time. ►
► Your (Proxy) Signature (Required) Relationship to Patient Date I acknowledge that I have read and understand this MyChart Sign-­‐up form. I agree to its terms and choose to designate the person named above as my MyChart Proxy, thereby allowing them access to my MyChart medical record. ►
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Signature of Patient (or authorized person) (Required) Relationship to Patient Date Teen Proxy Authorization for Release of Medical Information This form is an authorization that will permit Our Lady of the Lake Ascension, L.L.C. d/b/a St. Elizabeth Physicians, The Baton Rouge Clinic, AMC, Our Lady of the Lake Physician Group, L.L.C., and certain outpatient departments of Our Lady of the Lake Hospital, Inc. to release your medical information to your designated adult proxy. Please read it carefully. This form should be completed by the patient who is authorizing an adult to access medical information in his or her MyChart record. It must accompany the Teen Proxy Form, which provides the name and information of the individual who the patient is authorizing to access their MyChart record as a proxy. If you do not have a Teen Proxy Form, please contact your clinic, or download one from https://mychart.casso.us.com. Patient Name (last, first, middle initial) ______________________________________ Social Security Number: Date of Birth: _____
I am requesting that (insert name of proxy) receive access to my health information that is available in my CASSO MyChart Record. This person is my designated MyChart proxy. I authorize Our Lady of the Lake Ascension, L.L.C. d/b/a St. Elizabeth Physicians, The Baton Rouge Clinic, AMC, Our Lady of the Lake Physician Group, L.L.C., and certain outpatient departments of Our Lady of the Lake Hospital, Inc. to release the health information contained in my MyChart record to my MyChart proxy. I understand that the medical information in MyChart is obtained from my electronic medical record and may include information from all facilities listed in CASSO’s Notice of Privacy Practices. I authorize release of any information contained in my MyChart medical record held by Our Lady of the Lake Ascension, L.L.C. d/b/a St. Elizabeth Physicians, The Baton Rouge Clinic, AMC, Our Lady of the Lake Physician Group, L.L.C., and certain outpatient departments of Our Lady of the Lake Hospital, Inc. to my designated proxy. I authorize release of this information only through my MyChart record. This form does not authorize release of my medical record to my designated proxy by other methods or in other forms. I understand that once information has been disclosed, it potentially may be re-­‐disclosed by the proxy and the disclosed information may not be covered by federal privacy protections. Participation in MyChart and designating a MyChart proxy is completely voluntary. I understand that I am not required to designate a MyChart proxy and I am not required to provide this authorization. I also understand that Our Lady of the Lake Ascension, L.L.C. d/b/a St. Elizabeth Physicians, The Baton Rouge Clinic, AMC, Our Lady of the Lake Physician Group, L.L.C., and certain outpatient departments of Our Lady of the Lake Hospital, Inc. 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 authorization, Our Lady of the Lake Ascension, L.L.C. d/b/a St. Elizabeth Physicians, The Baton Rouge Clinic, AMC, Our Lady of the Lake Physician Group, L.L.C., and certain outpatient departments of Our Lady of the Lake Hospital, Inc. is not permitted to provide access to my MyChart record to my designated proxy. This authorization will expire automatically one year from the date of my signature. I also may revoke this authorization at any time by providing a written request for revocation to my primary clinic. I understand that if I revoke this authorization, my designated proxy’s access to my MyChart record will be ended. I also understand my revocation will not affect any disclosures that were made prior to processing the revocation request. Date: Primary Clinic: ______ Signature of Patient: Printed Name: ______ If person other than the patient signs, indicate authority to sign for patient (e.g., guardian) and attach documentation: NOTE: Authorization expires one year from the date of signature (above). A new MyChart Proxy Authorization Form must be submitted each year to renew proxy access. You also may deactivate the access of the adult proxy specified above at any time through MyChart or by providing a written request to your primary clinic. MyChart is a registered trademark of Epic Corporation