Mybmgchart Proxy Request For Adult - Buffalo Medical Group (Page 2 of 2) in pdf

MYBMGCHART

PROXY ACCESS REQUEST (ADULT)

This form is an authorization that will permit Buffalo Medical Group to release your (the patient) electronic medical record

information to the adult that you have designated and authorized to access your MyBMGChart account. You have the opportunity

to opt out of or revoke the access at any time.

To request access to the record of an adult through MyBMGChart, please complete this form. The patient whose

information you are requesting to access must sign this form. Please note that the patient’s chart will be accessed through

your MyBMGChart account. Return completed forms to the health care provider from whom this form was obtained.

IS THE PROXY A CURRENT PATIENT OF BUFFALO MEDICAL GROUP? Yes or No (circle one)

Your (Proxy) Information (All sections required – Please print clearly.)

This section should be completed by the individual requesting access to another adult’s MyBMGChart record.

Name (last, first, middle initial)

____ ______ Date of Birth

_______

Street Address:

__________ City:

_____ State:

Zip:__________

Phone Number:

___________________ Email:

_______

Social Security #_________________________

Patient’s Information (All sections required – Please print clearly.)

Complete this section with information about the patient whose MyBMGChart record you’re requesting to access.

Name (last, first, middle initial)

____ __Date of Birth

_____________

Street Address:

__________ City:

_____ State:

Zip:_________

Phone Number:

___________________ Email:

_____ MRN ________________

MyBMGChart Terms and Conditions

The use of MyBMGChart is governed by the MyBMGChart Terms and Conditions and the MyChart Proxy Terms

and Conditions of Use, a copy of which may be accessed when you sign in to your MyBMGChart account and

whose terms are incorporated herein. By signing below, you agree to be bound by the MyBMGChart Terms and

Conditions and the MyChart Proxy Terms and Conditions of Use. If, for any reason, you do not agree to be

bound by the MyBMGChart Terms and Conditions and the MyChart Proxy Terms and Conditions of Use,

MyBMGChart proxy access will immediately be terminated.

____________________________________/____________________________/__________________

Your (Proxy) Signature – (Required)

Relationship to Patient

Date

I hereby designate the person named above as my MyBMGChart Proxy, thereby allowing him/her access to my

MyBMGChart medical record.

___________________________________________/______________________/__________________

Signature of Patient or Authorized Person – (Required) Relationship to Patient

Date

I hereby approve this proxy access:

__________________________________/ ___________________

Physician Signature

Date

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Mybmgchart Proxy Request For Adult - Buffalo Medical Group Page 2

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