Authorization For Proxy Access To Khn Patient'S Khnmychart Account printable pdf download

Authorization for Proxy Access to KHN Patient’s KHNMyChart Account

Requirements and Procedures

This form may be used to authorize proxy access to another person’s KHNMyChart account for the following

purposes:

Access by Power of Attorney of a patient;

Access by parent or legal guardian of a minor child patient under the age of 14 years old;

Access by a parent or legal guardian of a minor child patient age 14-17, with the written consent of the

minor child patient; or

Access by caregiver or family member assisting with care of a patient.

The general requirements for proxy access to a KHNMyChart account record are:

 Each individual requesting access to a KHN patient’s KHNMyChart account record must have their own

KHN MyChart account or KHN clinic staff will set up account to allow access to the other person’s

KHNMyChart account record.

 If the individual requesting access does not have a KHNMyChart account, the KHN clinic staff will

provide a KHNMyChart Activation Letter with instructions on how to create one.

 This Authorization Form must be completed and signed.

 KHN reserves the right to revoke proxy access to a KHNMyChart account record at any time.

 The appropriate box must be checked below.

Statement of person requesting proxy access -- I certify that I am (check one box, as applicable):

Power of Attorney

 Authorization: Individual requesting access must be the Power of Attorney of the patient and must

provide appropriate legal documentation of Power of Attorney to KHN.

 Revocation: Power of Attorney access to a patient’s KHNMyChart account record is revoked when the

Power of Attorney or other legal documentation is revoked. The individual with access as Power of

Attorney agrees that he/she will report the revocation or termination of Power of Attorney immediately to

KHN. The Power of Attorney agrees that he/she will not seek access to the patient’s KHNMyChart after

revocation or termination of Power of Attorney and that doing so constitutes an illegal invasion of privacy.

Birth Parent or Legal Guardian

 Authorization: Must be a birth/adoptive parent or other individual requesting access who has legal

guardianship rights for the minor child patient. Individual requesting access as legal guardian must

provide appropriate legal documentation of guardianship to KHN.

 Revocation: Birth Parent or Legal Guardian access to a minor patient's KHNMyChart account record is

revoked when:



Birth parent/legal guardian or child patient submits a request or revokes online.



Child patient turns 14 years old (parent/legal guardian must re-request access and child patient age

14-18 must consent to parent/legal guardian access to comply with Ohio law, which allows minors to

consent to treatment without parental involvement in limited situations).



Automatically when the child patient turns 18 years old (continued access may be requested by

resubmitting appropriate form for family/caregiver access).



Child patient advises KHN of his/her emancipated status.



Parent/parent or parent/child access disputes cannot be resolved.

If all parent/legal guardian access to a child patient’s KHNMyChart account record is revoked, the child

patient’s KHNMyChart access will also be revoked

Family/Caregiver

 Authorization: Individual requesting access as family/caregiver must have signed consent from the adult

patient.

 Revocation: Family member or other caregiver access to a patient’s KHNMyChart account record is

revoked when the patient or physician submits a request or revokes access.

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Authorization For Proxy Access To Khn Patient'S Khnmychart Account

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