Proxy Form

Requestor’s (Proxy) Information:
This section should be completed by and about the individual requesting access to another patients MyChart record.

First Name

Middle Name

Last Name

Social Security Number:

Date of Birth

Street Address:

City

State

Zip

Email Address:

Phone:

Relationship to Patient:

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 12-17, proxy will be granted partial access to the minor patient’s MyChart record if minor consent to partial access on page 2 of this document. (e.g. appointment scheduling, immunizations).
If minor patient is between the ages 12-17, proxy will be granted full access if minor patient consents with signature on page 2 of this document.
Once the patient reaches 18 years of age, proxy will no longer have access to the patient’s MyChart record unless the patient consents to access.
Adult to Adult or Diminished Capacity, proxy will be granted full access to the patient’s MyChart record.

Patient’s Information
Complete this section with information about the patient whose MyChart record you’re requesting to access.

Please provide the following information for each patient: (All fields are required. If you have more than one patient for whom you would like proxy access, please submit another form.)

First Name

Middle Initial

Last Name

Social Security Number:

Date of Birth

Street Address:

City

State

Zip

Email Address:

Phone:

Primary Clinic:

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

Date:

TEEN ACCESS ONLY: For minor patients between 12-17 years old, please sign below to grant your proxy PARTIAL MyChart access: I hereby understand that with my signature I am granting the proxy indicated above access to limited information which includes scheduling appointments, viewing immunizations and billing information.

Signature of Patient (Parent/guardian CANNOT sign for patient here)

Date:

FULL ACCESS ADULTS AND MINORS 12-17: To grant your proxy FULL MyChart access.

I am requesting that (name of proxy) receive access to my health information that is available in MyChart. This person is my designated MyChart proxy. I authorize MyChart 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 health record and may include information from all facilities listed in Notice of Privacy Practices. I authorize release of any information contained in my MyChart to my designated proxy. I authorize release of this information only through my MyChart record. This form does not authorize release of my health 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 the same 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 MyChart 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, MyChart is not permitted to provide my designated proxy access to my MyChart record. This authorization will expire automatically five years from the date of my signature. I also may cancel this authorization at any time online in MyChart or by providing a written request for cancellation to my primary clinic. I understand that if I cancel this authorization, my designated proxy’s access to my MyChart record will be ended. I also understand my cancellation will not affect any disclosures that were made prior to processing the revocation before my cancellation request is processed. Solicito que (escriba el nombre del apoderado) reciba acceso a mi información médica contendida en MyChart. Esta persona es mi apoderado designado de MyChart. Autorizo a MyChart para que divulgue la información médica contenida en mi expediente MyChart a mi apoderado de MyChart. Entiendo que la información médica en MyChart se obtiene de mi expediente médico electrónico y que puede incluir la información de todas las instituciones mencionadas en el Aviso de Prácticas de Privacidad. Autorizo la divulgación de toda información contenida en mi MyChart a mi apoderado designado. Autorizo la divulgación de esta información solamente a través de mi expediente MyChart. Este formulario no autoriza la divulgación de mi expediente médico a mi apoderado designado por otros medios ni de otras formas. Entiendo que una vez que se divulga la información, esta podría ser potencialmente divulgada por parte de mi apoderado y que la información divulgada podría no estar cubierta por las mismas protecciones de privacidad. La participación en MyChart y la designación de un apoderado de MyChart es completamente voluntaria. Entiendo que no tengo la obligación de designar a un apoderado de MyChart y que tampoco estoy obligado a entregar esta autorización. También entiendo que MyChart no condicionará mi tratamiento médico, pago u otros servicios basado en si entrego esta autorización o no. Sin embargo, también entiendo que si no doy esta autorización, MyChart no puede otorgar acceso a mi apoderado designado a mi expediente MyChart. Esta autorización vencerá automáticamente en cinco años a partir de la fecha de mi firma. También puedo cancelar esta autorización en cualquier momento en línea en MyChart, o bien, mediante una solicitud de cancelación por escrito que debo presentar en mi clínica primaria. Entiendo que si cancelo esta autorización, el acceso de mi apoderado designado a mi expediente MyChart terminará. También entiendo que la cancelación no afectará las divulgaciones realizadas antes del procesamiento de esta solicitud de revocación.

Signature of Patient

Date:

If person other than the patient signs, indicate authority to sign for patient (e.g. guardian) and attach documentation:

Upload documentation

Authorization expires five years from the date of signature (above). This release of medical information form must be submitted every five years to renew proxy access. You may deactivate the access of the adult proxy form specified above at any time through MyChart or by providing a written request to your clinic.

Proxy FormFormulario para apoderado

Access to Another Patient’s or your Child’s MyChart RecordAcceso al expediente MyChart de otro paciente o de un menor (acceso como apoderado)

Proxy Form

Access to Another Patient’s or your Child’s MyChart Record