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Proxy Form


Requestor’s (Proxy) Information:
Please note the following age range limitations for MyChart. These age range limitations do not affect any legal right you have to access the patient’s record by other means. To request a paper copy of the patient’s record, contact Heath Information Management at 612-873-3180.
  • If minor patient is between the ages of 0-11, parents/legal guardians will be granted full access to the minor patient’s MyChart record.
  • If minor patient is between the ages of 12-18, parents/legal guardians will be granted partial access to the minor patient’s MyChart record (e.g. appointment scheduling, immunizations).
  • Once the minor patient reaches 18 years of age, parents/legal guardians will no longer have access to the patient’s MyChart record unless the patient consents to access.
  • Adult to Adult or Diminished Capacity: Parents/legal guardians will be granted full access to the patient’s MyChart record.
Patient’s Information

MyChart Terms and Agreement
  • I know that MyChart is a secure online place for confidential medical information. If I share my MyChart ID and password with another person, that person may be able to look at my health information, my child’s health information, and health information about someone who has given permission for me as a MyChart proxy.
  • I agree that it is my responsibility to select a strong password and to not share my password with other individuals, and to change my password if I think someone might know it.
  • I know that MyChart contains some medical information from a patient’s medical record and that MyChart does not contain the complete contents of the medical record. I also understand that a paper copy of a patient’s medical record may be requested from Hennepin Healthcare, Health Information Management by completing a Release of Information Request.
  • I know that my activities within MyChart may be tracked by computer audit and that entries I make may become part of the medical record.
  • I know that access to MyChart is provided by Hennepin Healthcare as something helpful for its patients and that Hennepin Healthcare has the right to turn off access to MyChart at any time for any reason.
  • By signing below, I state that I have read this MyChart Proxy Form and agree to its terms.

Signature of Proxy


OPTIONAL: For minor patients between 12-18 years old, please complete this section to grant your parent/guardian FULL MyChart access.

I   hereby understand that with my signature I am granting my parent/legal guardian access to my medical information including, but not limited to: medications, past and future appointments, all messages to and from my provider(s), test results, immunizations, and billing information.




This form is an authorization that will permit Hennepin Healthcare to release your health information to your designated adult proxy. Please read it carefully.

This form should be completed by the patient who is authorizing another adult to access health information in his or her MyChart record. It must accompany the Adult Proxy Form, which provides the name and information of the individual who is the patient is authorizing to access their MyChart record as a proxy.


Patient’s Information

Signature of Patient