My Health Connection Child Proxy Access Request Form Page 2
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2My Health Connection
Child Proxy Access Request Form
Proxy understands and agrees to the following:
I will follow the terms and conditions on the MHC web page.
I must log in to MHC with my own user name and password.
Communications conducted through MHC will become part of the patient’s medical record.
My access to this patient’s MHC account will expire in accordance with the access policy outlined above. Access
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to my child’s chart will vary depending on my child’s age. Access will expire on the child’s 18
birthday, unless
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otherwise specified. Access granted by this form will expire on the child’s 18
birthday, the child then has the
option to grant Adult Proxy access.
If I am a proxy acting on behalf of the patient because he/she is not able to make and understand health care
decisions, I agree to notify UCHealth in writing immediately at one of the addresses below if my legal authority
to act on behalf of the patient is inactivated, revoked, terminated or expired.
_______________________________________________
_______________________
Proxy Signature
Date
Please return this form to one of the following locations:
Memorial Hospital
University of Colorado Hospital
Medical Center of the Rockies
Health Information Management
Health Information Management
Poudre Valley Hospital
Department (Room 2402)
Attn: Release of Information
Health Information Management
Attn: Release of Information
Mailstop AO25
Attn: Release of Information
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1400 E. Boulder Street
12401 E. 17
Ave
2500 Rocky Mountain Ave.
Colorado Springs, CO 80909
Aurora, CO 80045
Loveland, CO 80538
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