Adult Mychart At Nyu Langone Proxy Access Request And Authorization Form
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1Adult MyChart at NYU Langone Proxy Access Request and Authorization Form
Requirements and Procedures
•
Proxy access to the MyChart at NYU Langone record of an adult may be granted by the patient or his/her legal
representative.
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Both the person requesting access and the patient or his/her legal representative must sign this form.
•
The proxy must have his/her own MyChart at NYU Langone account because the patient’s chart will be accessed
through the proxy’s MyChart at NYU Langone record.
I understand that:
•
MyChart at NYU Langone is intended as a secure online source of confidential medical information.
•
MyChart at NYU Langone is not to be used in an emergency.
•
Use of MyChart at NYU Langone is voluntary and I am not required to authorize proxy access.
•
I must select a confidential password to maintain my password securely and change my password if I believe it
may have been compromised in any way.
•
If I share my MyChart at NYU Langone ID and password with another person, that person may be able to view
my or my child’s health information, as well as information about any adult who has authorized me as a MyChart
at NYU Langone proxy.
•
If I have proxy access, I must log in to my own MyChart at NYU Langone account and click on “View Other
Records” to access another patient’s record.
•
MyChart at NYU Langone contains selected, limited medical information from a patient’s medical record and is
not the complete medical record.
•
My activities within MyChart at NYU Langone may be tracked by computer audit and entries I make may
become part of the medical record.
•
Access to MyChart at NYU Langone is provided by NYU Langone Medical Center as a convenience to its
patients and that NYU Langone Medical Center has the right to deactivate access at any time for any reason.
Completing this form will establish a MyChart at NYU Langone record for the patient and proxy. Return
completed forms to your provider’s office or to _________________________________.
If you already have a MyChart at NYU Langone account, you will receive a MyChart at NYU Langone message when
access to the additional patient’s record is available, typically 5 to 7 business days after completed request and
authorization form is received.
PROXY: I am requesting access to the medical information available on MyChart at NYU Langone for the patient
named below and agree to abide by the above terms and conditions of MyChart at NYU Langone and all other terms and
condition viewable online within MyChart at NYU Langone.
Name:__________________ Date of Birth:______________ Email: ___________________
Address/Phone #:___________________________________________/__________________
________________________________/___________________________/_______________
Proxy Signature
Relationship to Patient Date
PATIENT OR PATIENT REPRESENTATIVE: I acknowledge that I have read and understand this Request and
Authorization Form. I agree to its terms and choose to designate the person named above as my MyChart at NYU
Langone Proxy, thereby allowing my proxy to access my MyChart at NYU Langone medical record.
Name: _________________ Date of Birth: ______________ Email: ____________________
Address/Phone #:___________________________________________/__________________
________________________________/___________________________/_______________
Patient or Representative Signature
Relationship to Patient Date
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