Authorization For Adult Proxy Access To Mychart Form - Duke University printable pdf download

Patient Name: ___________________________________________

Date of Birth: __________________________________________

Medical Record #:_______________________________________

Authorization for Adult Proxy Access to MyChart

(Last up-dated 8-30-16)

I authorize and request Duke University Health System* and Private Diagnostic Clinic PLLC* (“Duke”) to grant my designated personal

representative identified below (Proxy) access to portions of my electronic protected health information, including, clinical and billing

information, maintained through Duke MyChart.

Proxy Name:

Email:

_____

Address: Street: ______________________________

____

________

___________________

City

State

Zip

Electronic Protected Health Information in Duke MyChart

Secured Messaging

Appointments

Test Results

Medications

Allergies

Immunizations

Preventive Care

Medical History

Hospital Admission

Track My Health

Billing & Insurance

My Account Letters

Diagnosis

Current Health Issues

I Understand That



Information to be released in Duke MyChart may include mental health, substance abuse or STD diagnosis, treatment or medications



I may revoke this proxy authorization at any time by clicking the “Revoke access” button while logged into my Duke My Chart account, by

accessing the section titled “My Account,” and then opening the sub-section titled

”My Family’s Records, “where I will see a list titled “Who can view my record?” I can also ask my provider to revoke this access, I can

call Duke Medicine Health Information Management at 919-384-7119 or I can send written notice to DUHS Health Information

Management, Box 3016, Durham, NC 27710. Such revocation shall not affect disclosures prior to the revocation.



Information disclosed pursuant to the authorization may be subject to redisclosure by the Proxy and may no longer be protected by the

HIPAA Privacy Rule.



This authorization is voluntary. If I do not sign or I revoke this authorization, Duke will still provide treatment to me and will seek

payment for services provided.



This authorization is valid unless and until I revoke the Proxy’s access.

Expiration

I understand that Duke MyChart access is a privilege, not a right, and that my Proxy must agree to comply with the Duke MyChart Terms and

Conditions. DUHS will provide my Proxy an activation code and instructions for accessing electronic protected health information about me in

Duke MyChart. If my Proxy does not accept and at all times comply with the Terms and Conditions, I understand that DUHS may deny my

Proxy access or revoke my Proxy’s access Duke MyChart. I also understand that Duke may deny my Proxy access or revoke my Proxy’s access

for any reason and at any time in Duke’s sole discretion.

_______________________________

Signature of Patient

Date

*All references herein to “Duke” shall refer to Duke University Health System, Inc., Duke University and any and all of its controlled affiliates,

including without limitation Duke University Affiliated Physicians, Inc., d/b/a Duke Primary Care and Associated Health Services, Inc. and

Private Diagnostic Clinic, PLLC and any and all of its controlled affiliates including without limitation Regional Anesthesia, PLLC and

Regional Psychiatry, PLLC.

COMPLETED FORM should be returned to:

DUHS Health Information Management.

E-mail at:

ROI-Requestor3@dm.duke.edu

Standard mail at: DUMC 3016 

Durham NC 27710

Fax at: 919-384-7148

Authorization For Adult Proxy Access To Mychart Form - Duke University

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