Mybmgchart Proxy Request For Adult - Buffalo Medical Group printable pdf download

MYBMGCHART

PROXY ACCESS REQUEST (ADULT)

________________________________________________________________________

Please read this form carefully before signing. This authorization will permit Buffalo Medical Group to

release portions of your electronic medical record information to the person listed on page 2 of this form.

I understand that use of MyBMGChart is voluntary. I am not required to use MyBMGChart or authorize a

proxy.

_____________________________________________________________________________________

Type of information to be disclosed: I understand that this authorization may cover disclosure of information

relating to alcohol or drug abuse, pregnancy, sexually transmitted diseases, genetic testing, psychiatric care

and/or confidential HIV-related information. In the event any of your medical information contains such

information, by signature at the end of this form, you specifically authorize its release to the person (proxy)

named below.

Method of Disclosure: My medical information will be disclosed to the person listed below through

MyBMGChart.

Redisclosure: I understand that if I authorize the release of HIV-related information, the recipient is prohibited

from redisclosing such information without my authorization, unless permitted to do so under state or federal

law. I understand that once my information is released pursuant to this Authorization, it could be disclosed to

others and would no longer be protected by federal privacy regulations. If I have a concern about HIV-related

information, I may contact the NY State Division of Human Rights at 1-800 523-2437.

Expiration: This authorization for release of information to my proxy will expire only upon my written

revocation or when Buffalo Medical Group is notified on my death or the death of the person I have authorized

to access MyBMGChart.

Revocation: I can change my mind and revoke this proxy authorization at any time, except to the extent that

anyone has already taken action based on this authorization. I can revoke my proxy authorization online

through MyBMGChart or I can send a written request to: Buffalo Medial Group ____________ Department,

____________________________________ . I understand that Buffalo Medical Group can also revoke access

to MyBMGChart for patients or proxies at any time and for any reason.

Durable Authorization: I acknowledge that this is a durable authorization that will not expire in the event I

become incapacitated or incompetent.

Submitting the Proxy Form: Give this form to your Physician’s office or send the form to

___________________________________________ . Please allow two weeks for processing. You will

receive a MyBMGChart message once the proxy form has been processed.

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Mybmgchart Proxy Request For Adult - Buffalo Medical Group