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.
Este formulario es una autorización que permitirá a Hennepin Healthcare divulgar su información médica a su apoderado designado. Sírvase leerlo detenidamente.
Este formulario debe completarlo el paciente que autoriza acceso a su expediente MyChart a otro adulto. Debe estar acompañado del Formulario para apoderado de adulto, que provee el nombre y la información del paciente que autoriza acceso a su expediente MyChart a otro adulto, como apoderado.